Feeding Therapy: Interview with Anuja Katrak, (CertMRCSLT, HCPC)

Feeding therapy

Feeding Therapy

Our guest today is Ms. Anuja Katrak. Anuja is a speech language pathologist who runs a clinic in Mumbai. I’m excited about today’s session because Miss Anuja will talk to us about one of her specializations, feeding therapy. Now, whether your child is a picky eater or has more involve feeding difficulties, you will find much to help you in today’s episode about meeting your child’s nutritional needs. Hello Anuja! I’m pleased to have you here. Can you tell us about yourself and what you do?

Hello, thank you so much for having me here today. So, I’m a speech and language therapist. I’ve also specialized in dysphagia, which relates to swallowing difficulties. This could be anywhere from feeding, eating, chewing, and all the way down to swallowing. I work with children as well as adults because I’ve super specialized. And so I work with children in the capacity of late talkers, developmental delays, things like articulation difficulties, but I also work with adults who have speech-language or swallowing difficulties. So, this would typically be adults who have neurological conditions or brain-injured patients. And I typically see children at my clinic, and the adults are usually at the hospital and home visits.

Oh, lovely! So you see children and adults. You must have a range of skills then.

Well, yes, I have super specialized in both. So I think that does give me quite the blessing to be able to work with both.

So Anuja, all our listeners may not be aware of the role of a feeding therapist. What does a feeding therapist do?

So today we’re focusing on more to do with children. I will narrate what a feeding therapist does more in relation to children. So, when we see children with feeding difficulties, it could typically be anywhere from the newborn stage all the way up until school-going, and the things that we usually target would be things like oral muscle difficulties, whether it’s low tone, whether it’s weakened muscles, it could be in coordination of the muscles, it could be hypersensitivities, in which case then we work alongside an occupational therapist. And then, we achieve the child’s feeding goals together. So the, feeding is really all about making sure that the coordination and the muscle strength is all coming together in order for the child to be able to eat without having any difficulties, whether it’s with the chewing or the swallowing.

Okay, I’ve seen a lot of children with sensory needs. You must be working with a lot of kids with cerebral palsy as well.

Yes, absolutely!

So what are the reasons that children have difficulty with eating?

It could be as typical as just a picky eater where in, when I say just a picky eater, it’s not something that we should ignore, of course, because that does spiral into all sorts of emotional issues as well. Right. But it could be picky eating wherein they haven’t really gotten comfortable with food from day one, which has then spiraled into difficulties accepting certain types of foods or textures or consistencies or temperatures.

But it could also be children who have an underlying condition, whether it is a neurological condition, whether it is underdeveloped muscles, whether it’s the coordination, which is typically apraxia. And so there could be several reasons why they might have a difficulty eating.

But I’d like to say that the minute… if you as a parent notice that something’s not feeling quite right about the way they’re accepting food or the way they’re even playing with food when they’re really little. And then that translates into difficulties as they’re growing a little bit older, in terms of textures or in terms of sensitivities to textures or not being able to chew certain things or being…, some children gulp their food down. They just want to be on blended or mashed food, even into their twos and threes. I would say definitely get an evaluation to check whether everything is as per developmental age range and milestones and expectations, or whether something seems off.

So, is there an age where it is okay to give mashed or blended food or smoothies as their main meal?

Smoothies, no, should never be a main meal. Is there an age for when it is acceptable to give blended or mashed? That’s a great question because right from when the child starts, typically eating at around six months when you start offering solids to them, many people prefer to go the baby-lead weaning way, which is… wherein they offer whole but small enough foods for the child to pick up and just feed themselves.

But many people choose to go the traditional way, which is just starting with pureed foods and building it up there on, but typically, a combination of being fed and feeding themselves or just being fed. I would say each to their own and let the parent decide this. But, I’d also like to say that mashed or pureed food or blended food in any form should definitely not go past eight or nine months. You can start introducing solids even then.

So, what is your advice to parents who blend food for their children?

Please don’t do it! The reason being you’re not allowing your children’s muscles in the mouth to develop if you continue giving them blended foods. This hinders their ability to be able to swallow and develop a good swallow, mature swallow pattern, with stronger muscles. Because if everything is blended, it’s very easy for them to just gulp it down. They get used to that, and it just becomes a spiral. It becomes easy for the family as well because it’s quick. It happens quickly. It doesn’t make too much of a mess, especially if the child is being fed by an adult.

So, I understand that it’s easy. It’s easier for both, but I would say definitely avoid this because you’re setting them up for years of difficulties there, to do with their oral muscles as well as their feeding. And as you know, I mean feeding is such an integral part of our lives, isn’t it? Right from childhood into even our adulthood, everything, many things revolve around our meals, our conversation, and socialization. So mealtimes are important, and they should be fun and they should be enjoyable for all. The best way to do this is by setting it in a positive tone from day one.

Blended food really does weaken. It doesn’t allow for muscle development.

Yes, it doesn’t allow! Yes, correct.

How will parents know if their child needs feeding therapy?

Typically, things like, they’ll see their children, their child, or their children refusing foods that the family typically has at home. They may see them struggle with, if they’re being watchful about it, they may see them struggle with specific textures. They may see them struggle with particular kinds of foods. It could be things like, say, mushy things like a banana or paneer and feta cheese and ricotta cheese. And those all kind of fall into a similar category of textures. Maybe you see things like that happen.

They may see them avoid crunchy foods, if at all that might relate to some sort of a chewing difficulty. It might relate to some sort of jaw stabilization difficulty. There could be several reasons which we wouldn’t know unless we’ve assessed a child. But I like to say that parents know best; they know their children the best. So, when they see something, or they feel something’s not right about the way that they’re eating or the way they’re chewing, or the way they’re refusing foods…, I would say that would be their first sort of red flag to know that something might need to be looked into.

Okay. So, is there a specific age when feeding issues develop?

This often goes missed. So, feeding issues usually will show up shortly after solids have been started. You might see a few things happening here and there which are very easy to miss. Because typically, parents start their children on pureed foods. And of course, like we just spoke about, that’s so much easier to manage in the mouth. So shortly after, as they keep increasing the progression of the foods and they start giving not pureed or blended food, but slightly soft, solid foods or completely regular stable food that adults eat, which is solid food, they will start seeing some sort of a difference.

So, there’s no specific, ‘one particular age at which something will happen, and if not, then you’re good to go for life.’ It can happen at any point during the progression of learning how to eat because the muscles are still developing. So, I would like to say then, to the parents, look out, be watchful! Watch your children; see how they’re managing. Let them do as much as they can on their own, but be aware, be aware of what’s going on so that you know when there’s something that might seem like it’s not going as you thought it should, you can just have an inquiry about it and check into it.

Okay. I think that’s where a lot of parents struggle. They’re not sure whether ‘is this serious enough to go ask for help or is it something that I just have to deal with?’

So, this is an absolutely great point that you brought up because most of the families that I’ve seen, ‘it’s always not serious enough to ask for help.’ I think the entire narrative around picky-eater is underplayed so much where people tend to feel or believe that picky-eaters…, I mean, it’s just something that you live with, and there’s nothing that can be done about it. Or there’s nothing that needs to be done about it because it’s just a picky eater!

But professionally, from my standpoint, the issue with that is that it’s not just a picky eater. There’s always a reason why that’s happening, and initially, it might seem quite miniscule that, okay, they’re just refusing. “Okay, my child only wants to eat bhendi, or my child only wants to eat one particular vegetable.” And they’re happy. They’re happy that they’re eating a vegetable without realizing that there’s something more going on, preventing them from being able to enjoy the other foods. And what we try to do is, what our aim should be, is to help them pick this up as early on as possible so that they don’t spiral into something as “Picky eating, oh, it’s not a big deal; they’ll manage. They’ll grow out of it.” They typically don’t grow out of things like this.

Because this then becomes a learned behavior to only accept certain textures or only be able to choose certain things without realizing that it’s actually difficult for them either emotionally or, physically, or anatomically. So, there’s always some underlying reason. So, the best to do at that point would be to just check up; and have an idea of what might be going on and what things there are that you can do to help your child. And then decide whether it still is small enough that you think you want to do nothing or it is something that you would rather tackle early on.

That’s right. A picky eater usually doesn’t meet all their nutritional needs because they eat a few things but not the variety of foods that any other child might eat. So, what is the evidence behind feeding therapy? Is there only one technique, or are there multiple approaches?

There are multiple approaches. It really depends on what the issue is that you face with the child. So, for example, if the child has weakened muscles, the technique to work upon strengthening their muscles like the tongue muscle and the cheek muscles. If that requires strengthening, the techniques and strategies for that would be different from a child who has, say, sensory issues and is hypersensitive or hyposensitive and needs assistance from a feeding therapist and an occupational therapist to overcome the sensitivities. So, the techniques and approaches definitely differ. The best is to way to understand what is going to work for your child is to do an assessment where the speech therapist who specialized in feeding and or the occupational therapist is able to assess what the issue is and then decide what the best way and the best approaches and strategies are forward.

Okay. I have heard something about desensitization for children with sensory needs. How does feeding therapy work? What skills are taught in feeding therapy?

So, the skills that are taught in feeding therapy again differ depending on the difficulty that the child is facing. So typically, the way I like to, to conduct my sessions are very fun and play based. So, the child is coming in to just have a great time, play around; if they’re older, then we chat, and we play, and they, from their perspective, they’re coming to just have a great time and then leave. But the first skill that I would like to teach in feeding therapy is ‘food is fun.’ There’s nothing more than that. Food has to be fun. It has to be a positive environment. It has to be fun for the family, for the parents, for the child.

Once we cross that hurdle, where mealtimes are not manic, where meal times are not stressful for anybody and they’re pleasant and fun, we’ve really accomplished more than half our work. So, once we’re able to establish the fun in food, then I move on to the specific skills depending on what the issue is, whether it’s a muscle issue, whether it’s a coordination issue, or whether it’s a sensory issue.

So, children do eat much better after feeding therapy!

Yes, a hundred percent!

I think that’s something that parents would love to hear.

Yes, absolutely! And not just eat better. I would say eat happier, and that should be our goal that the child is happier when they’re around mealtimes, and around other people having meal times, rather than it being stressful.

What role do parents or caregivers have in feeding therapy? How can parents help at home?

Of course, the primary job is on the feeding therapist. There’s no doubt about that. But the parents and the caregivers at home have a very, very important role because if you go to think about it, a child might come for feeding therapy maybe twice a week, maybe at the most, three times a week, and for thirty minutes, forty-five minutes. It’s not a long time. If you calculate that in terms of the entire week they might get an hour, an hour and a half of feeding therapy the entire week.

So, a lot of this has to be carried forward at home because in order for them to be able to carry over their skills from our clinical environment into their home environment, their school environment, and their social environment, they need help and assistance from their parents and caregivers to take this forward outside. So that’s when parents become, their role becomes very important because they have to be on the same page. We all need to be on the same page because that’s most important in enabling the child to be able to have consistency and carry over, which is key to their success.

Do the parents come into the therapy room when you are in session?

So, this is very child specific. If I feel that it is very important for the parent to be participative in this session or come in just for a part of the session to observe exactly how things are done, I would certainly have the parent in the session. But if I don’t need to demonstrate anything to the parent, or I don’t have any participative need for them within our session, I typically prefer them to be outside because this usually enables me to have an independent rapport with the child. It enables the child to feel free and not conscious or not extra uncomfortable and, therefore, do nothing with me. So, for several reasons such as these, I would prefer that the parent is outside. Like I said, unless there’s a specific reason for them to be in.

Okay. So, then you give the parent suggestions once the session is over.

Absolutely! So, there’s a feedback time after the sessions within which the parent or the caregiver gets feedback. Very often, they do have the liberty to send me a message or call me for feedback as well, which we then schedule.

Okay. How long do you see a child for therapy typically? Is it three months, or is it child-specific? How does that work?

Yes. Yeah, absolutely! This is a question I get from parents all the time, and it’s a very difficult question to answer, but a very fair and valid one which I empathise with because you do want to know that there’s going to be an end to this, and when is there going to be an end to this or? How soon we can experience success at home as well and make meal times less stressful? So, I understand that.

But unfortunately, this isn’t medicine. It is therapy and it requires a lot of time and patience, and understanding. So, the variables involved in deciding how long it’s going to take, how many…, so it depends on, say, for example, how often the child comes, whether they come once a week, twice a week, or five days a week or six days a week.

Obviously, the more often they come, the faster the progress because the faster the carryover as well. It also depends on how much follow-up is done at home. So, we have parents who are really on the ball and follow up extremely diligently. And then of course you see progress happening a lot faster in those situations as well.

It also depends on consistency. The child may be scheduled to come in three times a week but may actually end up coming only once or twice in a month. And then that needs to be brought up with the parents and discussed with them because they’ve signed up for…, being aware that this is going to need three times a week in order to experience progress. But the consistency or the regularity of sessions doesn’t end up being the way it needs to. And then that impacts progress. So, there are many variables. It’s not only what happens inside the clinician’s room.

So, I would say, “Be patient all in all,” but usually what I can do with my, with the families I see is that, once I start seeing the child and I start seeing how the child is responsive to me and how consistent they come, how well the follow up is at home and then usually be able to sort of give some kind of an idea of whether it’s going to take two or three months, or maybe six or seven months, or maybe longer.

Okay! So do you have to do a lot of counselling with parents?

Yes, that’s right, absolutely. A lot of counselling is a part of our job as well.

Yeah, because parents get so stressed about the feeding aspect. Plus they feel guilty, I guess.

Understandably.

It can’t be just giving them strategies.

Absolutely, absolutely!

Is there an optimum age to see the best results of feeding therapy? The younger the better, I’m assuming.

Absolutely, early intervention is always the best. There’s enough research backing that up. So that the optimum age is as early as you think that there’s a problem, just have it checked. Usually, most therapists will tell you if there’s nothing to worry about, “go back. do these certain, maybe, strategies back at home and then follow up with me after, say, three or four months, if at all. But for now, you’re good. There’s no need.” Or if there is a need, they’ll tell you, and then you would have caught it as early on as you possibly did. And that will give you the best outcome.

So, is feeding therapy very useful for children across the board, you know, without any specific diagnosis? Or is it only for children with certain conditions?

So, children with certain, with specific conditions where you already know that there are likely to be feeding difficulties, of course, then that goes without saying that they will need feeding therapy. But there are many children, such as the ones that we often call picky eaters, who have no underlying diagnosis or underlying difficulties and have developed with their milestones fairly typically, but they may still have difficulties with feeding. So I usually, I wouldn’t say that this has anything to do with the diagnosis necessarily.

Okay. So, supposing parents want to take their child to a feeding therapist, what are some questions they must ask, the questions they must ask a therapist?

I think the first question that they really must ask is whether the therapist is dysphagia certified, has achieved their competencies, and is able to work with the issues that they feel that… that their child has. Because our field is very, very large. It’s very vast, and just being a speech and language therapist doesn’t mean that you’ve got all the experience required to be a dysphagia or a feeding therapist. You have your… the areas that you’re better at and the areas that maybe others are better at. So, I would say that the speech and language therapists that they see should have their dysphagia competencies and be a certified feeling therapist as well.

Do many colleges in India offer training for this?

So yes, there are a few colleges in India, across India, that offer the speech and language therapy programs.

But specifically for feeding therapy?

No. So, it’s a speech and language therapy program where they receive their degree and their experience in speech and language therapy. The level of dysphagia competencies, as well as the feeding therapy expertise that they get, might not possibly be linked directly, only to their practical experience. I could be not 100% right on this because I did not complete any of my degrees in India, but from the last time that I had found out, there were no specific dysphagia competencies. I can only hope that this has changed.

Okay, so where did you get your degree from? Where did you get this particular training from?

So, I first did my degree at Northwestern University in Chicago and…, and then I did my next degree in speech and language therapy, again from UCL in London. So that’s where the super specialization happened.

Anuja, thank you so much for sharing your expertise with us. I know I learned a lot from you, and you’ve given a lot of information to our listeners. And I hope that parents will listen to this podcast, will find the necessary professional support to help their children in a timely manner. Thank you again Anuja!

Thank you very much for having me. I can only hope that this creates as much awareness as you and I have planned for it too.

Read more on the causes of feeding difficulties:

Dysphagia

More than picky eating!

Other episodes in this series:

Speech, Language, and Communication in the Early Years

Mental Health and Counselling in India

Occupational Therapy and Sensory Intervention

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