Ep 336: Feeding Therapy in Schools: Safety, Culture, and Collaboration with Karen Howarth

So we're looking at all the aspects. Our reports tend to be like 12 and 13 pages long because we're looking at everything. We're looking at the mealtime routine at home. We're having the parents fill out a petty eat to see if there's, you know, restricted diet. Do they, do they have a pediatric feeding disorder?

Hi and welcome to episode 336 of the Untethered Podcast. Today we have Karen Howarth joining us. Karen has been a pediatric Occupational therapist for 25 years, specializing in feeding. She's worked in a variety of settings including early intervention, the NICU output, outpatient clinics, and for the past 13 years in the public school setting. She recently obtained her doctorate in 2023 and her research was focused on development and validity studies on meal time screening tool for the school setting. Karen is also a new OT mentor Inside Feed the Peas and we're so excited to welcome her to the team. Welcome to the Untethered podcast. I am your host, Hallie Balkan.

I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, airway tether, dural tissue and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest posture.

Tongue up, lips closed, teeth apart, breathe through your nose.

Let's get started.

Karen, welcome to the podcast.

I'm so happy to be here. Thanks for inviting me.

I'm excited that you're joining us. So before we jump in and have you share with everybody a little bit about, you know, who you are and your background, I just want to tell everybody that, you know, you recently joined us Inside feed the PEDs as our resident OT mentor and we're so grateful for you and so glad to have you on the team.

I'm so happy to be here. It's been such a great experience so far.

Well, I'm glad, I'm glad to hear that. So share with everybody a little bit about, you know, your background. Obviously you're a pediatric occupational therapist, but share, share about your background, what you're doing now. Sure.

So I have been a pediatric OT for, oh gosh, this is going in my 25th year. I have Only done pediatrics. I've worked in every possible setting and including the neonatal intensive care unit, outpatient clinics, early intervention, and most recently I've been working in the school setting in North Carolina. I have been specializing in feeding for the past 20 years. And through that journey, about two years ago, I finished my doctorate in occupational therapy from Columbia University, where most of my research was on developing a mealtime assessment tool or screening tool for the school setting. Because the role of OT and feeding has not been studied in the school setting. It's basically in homes, clinics, hospital settings. But yet there's no information on addressing mealtime challenges in the school setting where kids are spending six to eight hours of their day, five days a week. Yeah, so I have a wonderful husband and I have a six and a half year old who just started first grade today.

Oh, congrats. I have a seven year old going into second grade in about two weeks.

So yes, awesome.

Yes, Fun times. Oh, my goodness. Okay, so tell us more about this. Because you're sick. So it hadn't been studied at all OT feeding in the schools. And so you created, you did research to basically create a screening tool, right? Yes. Okay, so can you share a little bit more about that? Like what does a screening tool look like? How is and is it different in the school setting? Right. Than like a clinic, let's say?

Sure, I'll be happy to talk about it. So it's called Mealtime Screening for Schools or Meals for Short. So M E A L S S. I do have my own website now that the tool is available electronically as well as like hard copy. Being a member of the mealtime support team in the county that I work for, there was not really a whole lot of investigating or considering the environmental, the cultural factors, or the child actually participating in their meal. We were so focused on the physical parts and the biomechanics of eating and can they feed themselves? Are they chewing safely? Are they, you know, do they need a modified diet? And we weren't really looking at the engagement piece. So I saw this gap and when I got went to get my doctorate and I was like, this is what I want to focus on. So I developed a screening tool and it looks at feeding performance skills, which is kind of, can they set up their meal? Can they feed themselves how much assistance they need? It also looks at the environment and context factors and it. And then the third category is it looks at mealtime behaviors. And it's a quick screening tool. Right now it's geared for occupational therapists of any level of experience. And it can be a screening tool for, okay, these are areas that are supporting or inhibiting mealtime participation in their academic environment. And from there there's this tool manual and also guidance on next steps. So if you find like the environment is one of the inhibiting factors, can the environment be easily changed? Can it be modified? If there's performance skills, can there be modifications easily made or do further evaluations are needed? Maybe in the community, maybe within the school setting, do IEP changes need to be helped? So it's kind of a stepping stone for next steps when there's a mealtime concern or mealtime issues. And so my plan is, and my hope is, is right now it's based on ages 5 through 10 years old, but I would like to extend it to secondary school age as well as the preschool school age and in hopes of making it multidisciplinary as well.

I love this.

Yes. So it's pretty quick. It's an observation. It's a guided observation. So there's a checkl. I believe there's 16 or 17 questions you can write comments about can be subjective because what you think might be inhibiting might actually be just a compensatory strategy for the child and they're still able to participate effectively. But it takes the length of an observation of a meal. So it takes in consideration all of those things and you know, that collaboration with disciplines afterwards. So if you're noticing, you know, really difficult time managing foods or needing a modified diet, it's like, I really need to get in touch with a speech pathologist about maybe this child needs a modified diet while they're at school or they're really struggling or we need to do some more education of the IEP team or the classroom staff. So that's in a nutshell.

I love that because, you know, a lot of people know that I've created like a screener now. I haven't done any like research on it or, you know, it just kind of was like, hey, I feel like we need this like, quick thing that helps us figure out if we need further assessment. But you know, while we might look at a little bit of the environment factor, it's really in behavior is really more so than the environment. To be completely honest. I think it's very more so it's much more geared at the like oral motor. Sensory. Oral motor skills. Right. Which are kind of like, this is where we were hyper focused. We need to be considering all these other things. So it sounds like, you know, you kind of captured all of that, which is amazing. I also think it's interesting too because, you know, I started in the schools and, and I was in the preschool, it was called PEP Preschool education program in the county that I was in. And I really wanted to go into the infant and toddler program, but they wouldn't let me do that right out of grad school. So I was the only person in the county where they let me split my time between two of the preschool programs. Most people had like preschool for like one little period of their week and then they had like elementary for the rest. And I was like, no, no, I don't want to do like six speech, language, reading, writing, like all that stuff. I want to do feeding. Like I want to do the stuff and I want to do it with like the little ones. I only want to work with the little ones. Like birth to three, I was like birth of five, I could do. So anyways, let me start in the preschool population. I split my time between two schools. It was very interesting because in one of them they just started the pet program and nobody knew what we did. They didn't understand why we were there working with these three to five year olds. And also feeding was like not a thing. And then I had the kids in the other school and there are two schools upcounty, one and down county, one school where it's a self contained school and goes K through 12, you know, or through. Basically when these children graduate from the public school system and move onward and you get a lot of your children who have more severe diagnoses and really need to be in those self contained classrooms. But the PEP program happened to be housed there and they had all different levels of the program and some of these kids would go on to the general education curriculum in a different setting.

So.

So in that school everybody seemed to understand what we did. But I was still told, no, no, we don't do feeding. And I was like, this makes no sense. You have to eat to access the curriculum. And I'm pretty sure legally, I mean. And I was like fresh out of grad school back in 2009 and like, I was like, I'm pretty sure, yes. Like legally you can't not give these kids support. Come to find out. So a therapist goes on leave and I inherit her caseload and she had a caseload of children who were non mobile, who were all in a classroom together, who all had a. Most of them had 24, seven aides with them and they all had feeding goals on their IEPs. What do you know, much to your surprise, it's like, wait, wait, wait, wait, wait, wait, wait. I thought we didn't do feeding here. And, like, what about all the kids in the other classrooms who also need the sensory oral motor skills? Okay, cool. Got it. So meanwhile, I am, like, thrown into this room where I'm watching children with cerebral palsy who are in a wheelchair who really don't have a lot of mobility that they can control. And, you know, not all of them, but most of them. And I'm watching, like, an eight or a feed down this kid's throat. The. The kid's head is like. The neck is in hyperextension. And I'm just going, I don't know anything, but I know that's not safe. And I just immediately from that point, like, threw myself into as much continuing education as I possibly could. And that was my introduction to the schools.

Yes.

Until I then left after two years, went to infant and toddlers for one year, did do feeding at infants and toddlers, but mostly the ots did it, so it was usually a co. Treat, and then left the schools altogether. So, anyways, that's my experience, but I know just from speaking with so many others that, like, feeding is not commonly addressed in the school setting. And so tell us, like, what's. I'm curious to just share with everybody, like, where are you located? What school system are you in? Is this something that any child can access? Or is there. Does it take a lot of advocating where you are?

So I'm in Raleigh, North Carolina, Wake County Public Schools. We are kind of making pathways, because we are. We have other districts across the nation and within North Carolina reaching out to us, wanting to know how we set up this multidisciplinary mealtime team. We're called MST Mealtime Support Team. And right now it's speech OT and physical therapy. And I kind of had the opposite experience of you. Like, I didn't start in the schools. I started in inpatient acute care, then went into specializing in, like, cardiac infants and then into the nicu. And so transitioning to the school setting was a big mind shift for me because I had such a medical base and foundation. So having to shift that into an educational frame of reference was a big challenge for me because I'm like, I'm just gonna. And also, like, your new therapist, you're like, I'm just gonna fix everybody. Well, you don't fix people. You don't fix people anymore. Like, get away from that mindset. And when I do some lectures and teach A couple of like core sessions at higher academia levels. I was like, you don't fix people. It's in our nature that we want to fix it, but don't, don't meet the child where they're at. What are the goals for the family? What are the goals for the child if they're able to express it. So we started this team about five or six years ago and it's been building an airplane while we're flying it. So because there is no gold standard to reference, we've reached out to other people. I know, like we've reached out to Emily Homer because she does a lot in the school setting and we've used some of her framework stuff. And then, I mean, I decided to go back and do more research for my doctorate because this is such a huge issue. So we've had to go through a lot of policy, a lot of procedures and it has to be educationally relevant. So we have to explain to parents like, oh no, no, no, you' not just going to come to school and get your feeding therapy there. Because we're taking an educational frame of reference. Of course we're using medical knowledge and we, you know, it see levels about diet recommendations or if they need thickener. But this is based on community medical knowledge such as, you know, swallow studies and you know, ENT or G tube feedings and everything like that. We can help them access their curriculum, making sure that they get their adequate nutrition and hydration. But we're not doing sensory based feeding therapy. And a majority of our cases lately have been arfid and picky eating. And it's difficult because of course you want a child to eat more than just beige foods and tortilla chips all day long. But if it's enough to sustain their energy so they can participate in their classroom, then we really can't intervene too much. So right now we are set up. Our mealtime team is set up for children who are accessing special education. We are operating through the IEP process and we are part of the IEP and children who have previous feeding difficulties. You know, we can get referrals to complete a mealtime evaluation and then we make recommendations based on that. Of course, we are in collaboration with community providers to make sure we're not confusing the child and that we're adhering to all the Dr. Recommendations and all the strategies that they're doing at outpatient. We're just not working on a lot of times progression.

Yeah, that's, it's very interesting. And that was one of the Things that just. I like, couldn't do it. It's one of the reasons why I left. I was like, I feel like I can do so much more for these kids and that my hands are so tied. And, you know, we have a bonus training that I think we still give. I have to check when. Yeah, we do. I was just checking Kajabi that we give to anybody who takes feed the peds. And it's basically dysphagia, feeding and swallowing in the schools. Because one of our initial co creators, Kristen west, who was with us like five years ago, she has a program like this where she oversees the program. I can't remember if she's in Pennsylvania maybe, but she oversees it. And so she basically goes in, creates the program, kind of trains the team on how to implement. And it sounds. You don't know if this is similar to what you guys are doing, but she was very in the know with all of like the, you know, legal aspects of getting something like this in place for a child. But I think it's really incredible and important what you highlighted that, you know, even though we are giving these children access to these services in the schools, it looks very different than your sensory, oral, motor feeding therapy that they may be getting any more medical type of model, be it a private practice, outpatient hospital setting and whatever, you know, so that people really do understand that it does look different.

Yes, and it is. You know, a lot of us on the team have, you know, 15 to 20 years experience and came from a medical model. So it's hard for us to turn off that hat of thinking at times, but we're trying to shift it and utilize it because, all right, we know that this child is not eating safely, so how do we keep them safe at school? You know, and then there's different frames of thought. Like the parent might not agree. And it's like, you know what, you can feed them whatever you want at home, but at school this is what's safest for them. And if you're worried about advancing their diet or progressing them, there are certain cases where we will develop chewing goals or oral motor goals to get them to a more age appropriate diet level. But that's not the common. It's more of a rare case situation. So. But yeah, it takes a lot of mind shift. And we're like, okay, now that we are beneficially been told by admin that we are part of the IEP process. Those are. Those boundaries were set for us.

Yeah, educational impact. Those were that term right there. It's like Is there an educate and is there more of a 25 than a 25% delay causing an access to the curriculum and their daily da, da, da. And I was like, these things are so forever burned in my brain. And I have not worked in this school since 2012, if that tells you anything.

Yeah, yeah. What's nice about our little mealtime support team is that we are not required to determine eligibility. There's other components. So there's. I believe there's 16 different areas of eligibility and there's different testing and assessments that need to be completed. When you're considering those areas of eligibility, mealtime is not one of them. So that's a caveat for us that we're not required to determine eligibility. We're just kind of like another related service bonus to address that part of it.

Yeah, that's nice. Because I feel like part of the eligibility component was, well, oh, in order for them to get this service, they have to be on SLP service. And in order for. It's like, well, who made that stupid roll up?

Yeah. And every state's different. Every state's different. You know, the things that there's disability states and they're non disability states, and so it's very different. Sometimes we get children from northern states like New York and New Jersey, and they're coming in with all of these intense goals that are being served three times a week. And we're like, wow, yeah, maybe once a week down here with how North Carolina system works.

Yeah.

Yep.

Yeah. Now, there was a lot of that discussion back when I was in schools too, where it's like, it would be nice to give this child 90 minutes a week and see them three times, three times 30, or to even do two 45 minute sessions a week. And honestly, in some cases, we were able to argue that the child really needed that, but those were more severe, you know, cases. Yeah, it was usually a one time a week, 30 minutes or 60 minutes or 45 minutes or whatever the case was. And it. Yeah, yeah, it all came down. And unfortunately, which is completely illegal and they can never tell you this, but it all came down to staffing. It all came down to the availability of what services they had available to fill. Because if they put it on the iep, they're legally required to fill it. So they would try to get off the iep. Yeah.

Which is unethical, but yes. Yeah.

And which is also another reason why.

I was like, I'm out, I'm done.

I don't like this place anymore.

I totally.

I Don't take Noel.

Yeah, I don't either. I don't either. But I've learned. I've learned the soft language and have come a far way. And like, no, I want it my way. And so, you know, just a lot of mind shift and not, you know, not taking no for an answer, but also not pushing back to the point where you know you're gonna lose your job.

Right, Exactly, Exactly.

But there's that piece of it. So, yeah, we have something really special and I'm glad to be a part of it and trying to educate more in our profession about the importance of addressing it because it's such a huge thing. It's so huge. And I know you knew this, but I presented at the North Carolina Occupational Therapy Association Conference this past fall, and then I also presented at the American Occupational Therapy Association National Conference in the spring about this importance and the work that I am trying to do in my spare time.

Were people, like, surprised to hear about it or people kind of like, oh, that's a thing.

Like, mixed. Like, some people are like, oh, wow, yeah, there isn't anything out there and this really needs to get addressed. And, oh, my district just tells us to stay away from it and don't do it. But what do we do with all these kids with the. It's almost a pandemic or epidemic with the picky eating and ARFID diagnosis and even pandas is coming up a lot too, with diet levels and things like that, that it's. You can't help but not address it. Right. If a child can't make it through their day because they're not safely eating or they're not getting enough hydration and nutrition, like, that's not fair to them. If we're not trying to provide free and appropriate education and them accessing the curriculum. So we have to intervene. Not like, oh, we're just going to put everybody on modified day and their parents can feed them when they get home. That's not fair either.

Or accountable. So how do you address it across, like, the various settings? Because obviously you're not controlling what's happening at home and what happens at school. Like, you've kind of said, well, we may have different goals at school than the parent may have at home because it's more about accessing the curriculum. And maybe they have their preferred food all day, but it gets them through the day. Right? Yeah. Is that like a big conversation?

It is. And it also depends on the family and it depends on the child. I mean, we do offer. I don't know if you're familiar with like the multi tiered system strategies mtss. So we have developed kind of MTSS strategies at the different tier levels with mealtimes and we're trying to eventually create a curriculum especially for those preschool classrooms so that meal time and positive mealtime exposures become part of the day. I like it. Yep, yep. So I mean that's, that's a huge goal. That is probably maybe 10 years down the road. But, but we, I mean some parents are like, I want all the help and we're happy to provide them resources. And you know, some, some kids, they insurance won't cover it or schedule is too crazy and they can't access the feeding therapy. So we should provide them with as much tools as possible and make sure that there's at least some consistency in the strategies that are being used at home and used at school. So even if it's not diet level, like oh well, I give him steak at home. Well, he's not really safe to eat steak at school, that's fine. But let's use the same visual cues, let's use the same verbal cues. It's the same prompting if they're overstuffing their mouth, like we're using the same verbiage, we're using the same visual cues. So we will often provide a set for the classroom as well as a set for home. So there's that consistency for the child but it's heavily, it's heavily child dependent and case to case. And then there's parents that don't comply at all and they've agreed to a certain diet level and that we have felt that and this physician has signed off on it and they're sending the child to school with food that is not safe. And then we deal with that ickiness of hey, we didn't feed what you sent in because it doesn't meet the criteria that you agreed upon. It doesn't meet the medical statement. So we do run in those situations as well where there's continued non compliance and that's when we get admin involved because it's a huge safety issue. We don't want, you know, child shouldn't be eating, you know, beef jerky steak and they should be on an easy to chew diet. We're not going to give that to them at school because if they choke then the school is liable.

Right. So fun times.

Yeah, yeah. Let alone IEP meetings.

So then explain for everybody because you know, some people might be going like, okay, I hear you talking about the differences in school versus like, like a clinic setting or outpatient setting. So how are you assessing these mealtime difficulties in the school setting? Right. Because it almost sounds like you still have to do more of a medical approach and an assessment. Right. To understand what's safe, what's not safe. And are you guys assessing or are you really relying on outside assessments only? Like, what does that look like?

Oh, so no, we are. We definitely. If the child gets referred and a mealtime evaluation is signed for and consented to by the parent, we conduct a full evaluation, depends on the child. Ot we tend to handle the lower tech, less complex seating. But if it's a child that's more medically involved, more medically fragile, and they're requiring more complex seating, we do have physical therapy come out with us. Sometimes we're seeing these kids over a span of like three or four weeks because we're trialing different things. We do also take the information, like any medical information. GI history, you know, nutritional supplements, are they growing? You know, is there any history of aspiration or dysphagia, NES history? So we take that all into account. But when we go out, we are physically scheduling during a snack time, during breakfast, during lunch, whatever they eat at school, what their current diet is. And prior to the evaluation, we staff are filling out a notification of mealtime concern that they check mark. Like they're concerned about the child's positioning or they can't feed themselves. So we're looking at all the aspects. Our reports tend to be like 12 and 13 pages long because we're looking at everything. We're looking at the mealtime routine at home. We're having the parents fill out a petty eat to see if there's, you know, restricted diet. Do they. Do they have a pediatric feeding disorder also? All their medical history, we get all of that. And I look at ot, we look at self eating, we look at sensory and positioning and equipment needs, and then we make recommendations based on that. So we are doing a quite comprehensive evaluation.

Yeah, so that's. That's helpful to understand because I think it's like. Yeah. Knowing that you guys at least are gathering all that information, you have, obviously, the, the comprehensive eval and everything to kind of back what you're doing is. I mean, that's great. I think that's great that you guys actually get to do that. You're not just depending on outside.

Yeah.

You know.

Yeah.

Input. And then so you mentioned kind of the multidisciplinary approach at times when needed for assessment. Do you also Ever take that approach? Are you able to take that approach for feeding like intervent?

Oh, absolutely, absolutely. Yeah, yeah, yeah, yeah. So when, once we complete our eval and if we are recommending a modified diet, we always send a copy of our report to the child's pediatrician so they can look over what we saw in the school setting. Because what might be going on at home and what might be going on at school are sometimes extremely different. And also taking into all those cultural factors and potential language barriers and sometimes there's unsafe practices going on at home. And then we will write up a mealtime support plan and it's interdisciplinary or multidisciplinary and we will both train school based staff. But it's often a mutual effort. I would say 99% of all the cases that we see are speech and ot. Okay, there is PT involved for the more, but I'm on almost every single evaluation case or every single case that comes our way. And we will look at, okay, what kind of sensory or pre feeding strategies need to happen prior to that? Do they need Z vibe? Do they need some heavy work? And then the speech therapists might be facilitating more of age appropriate chew pattern and I might be working on the self feeding part. So it's very much a collaborative effort.

Yeah. Okay, here's, here's a. I don't know if it's a loaded conversation or not, but so I feel like there's been a lot of discussion about being, you know, and being culturally sensitive and obviously very important to consider those cultural factors to consider, you know, because so when you guys are doing these evals, are you also going into the home and doing the observation there? How are you gathering that data?

Depends on the kid. We're typically not because it's educational relevance. We want to see the child eating in their educational environment. However, we do frequently if a child is not eating at all at school or the classroom or the team is really struggling with getting the child to eat at school, we will reach out to the family and be like, hey, can you send me a video of how they eat at home? And that's really, really helpful. So we can look at and attempt to set up things as similar as possible as long as they're safe and they're not making us roll our eyes with oh my gosh, they're just shoving that down that child's throat. So we do sometimes if a child has just moved to the country and they're new to the county and they haven't been placed yet because they don't know what is the best placement or eligibility. I have done some home evals for those kiddos to try to establish a safe diet for them for whenever they do get placed into the appropriate classroom.

Yeah, so I guess like, yeah, so I guess the follow up question to that is more than like, what are you, what are you doing, you know, to make it so that you're sensitive to any environmental or cultural, linguistic, you know, all the different kinds of differences, things that can be happening. Because if, let's say a parent, you know, I'm just imagining a situation where a parent is doing something that's unsafe, but maybe it's a cultural thing, like the parent feeds the child and it's seen it. Right. And you guys are going, but in feeding the child the way that you're doing this is unsafe. Like, how are you navigating these things as a school based?

Very carefully, very carefully. It depends on the family. You know, we've had a lot of cases where like, I have no problem getting them to eat at home and they're really just kind of shoveling it in and they're force feeding. And I was like, okay, well, we are very sensitive and be like, I'm so glad that that works for you at home. However, that is not a practice that we can get behind in the school setting because we're trying to give the child some autonomy and some control and we want them to be safe. So we're respecting that. And just, you know, there are a lot of cultures where parents will feed kids and feed them and feed them, feed them, and then they send them to school and they're like, I want them to learn how to eat by themselves. And it's like, that's great, we can work on that. But I really would love if you could pick some times to work on it at home as well. It's kind of like some parents were like, I want to fix, I want you to fix my child in one therapy session a week in the private sector and not carry over anything at home. So there's that carryover factor. And some families we get through and then there's other families that we don't. And then we kind of rely on the admin to help direct us. And unfortunately, there has been some cases where the practices that are going on at home are very, very unsafe. And we have to get the school social worker involved. And we, and we have to discuss with the pediatrician, like, do child protective services need to be involved? Because the way that this child is being fed is unsafe and Forceful and not safe for them. So every case is different and we just, we do what we think is within a relationship, what is ethical and what is best for the child, because that's our main focus. So. But in terms of like foods and cultural, you know, there are definitely some cultures where it is acceptable for the child to be fed. And if the child won't eat anything unless they are fed by an adult, then we have to make some accommodations in the school environment for them to access their education.

Yeah, thank you for sharing that because I, I just know people are probably though, like some of our listeners will be thinking, well, how do you go about that? And like what do you do in these tricky situations? And I, I mean I know in infants and toddlers there was a time where we walked into a home and the child was rolling their little car across weed on the, it was like spread right through the weed right across the table. And I was like, oh cool, okay. That's a fun way to start this eval. Right? And then we looked over and like the 4 year old is cooking themselves Mac and cheese on an open flame and I'm like, the kid can barely reach the pot. This is not okay. Well, this is a call to cps, you know, and it's, it's unfortunate. That's obviously for us at. Not obvious, but for us that was not the bulk of the cases. But you know, you always get some. Not always. You occasionally get cases where they're really tricky to navigate. And I think when it comes to feeding and it comes to cultural differences and it comes to just family differences sometimes it's not even a cultural thing, it's just this is how this family operates and we kind of, you know, but when it's unsafe, we then have that ethical obligation to unfortunately take certain actions. So. And I know especially with feeding these little ones, like it's.

Well, and they may have been premature and this is, this feeding issue has been long going and. Oh yeah, and it's a feeding battle, it's a huff. And I tell parents a lot. I was like, this is a marathon and not, not a sprint.

Yeah.

And then there's going to be lots of hills and valleys in this journey. I mean, and when you're a parent and you have a child with feeding difficulties, I mean, you're unable to meet their basic needs. And there's this tremendous amount of guilt that a lot of parents experience. And I think as a clinician, whether you're school based, private hospital, wherever, you have to take that into consideration because There is a lot of parental guilt going on. Like, my child doesn't feed well, it's all my fault. Like, it's my fault that they were premature. It's my fault that they have a feeding tube. And there's so much guilt that you have to be extremely sensitive to that and meet the parent where they are. We do a lot of education as much as possible, a lot of communication with parents, and we put in our best effort. And at the end of the day, I try to rest my head on. I did the best that I thought I could do for the family and the child.

Yeah, thank you for highlighting that because that was. I was gonna also kind of mention that, you know, it's. We never know what experience they've had to date, aside from what they share with us, which is not always the whole picture. A lot of the families that we. That I, you know, my team and I have worked with in the past, you know, and now they. They all have their individual journeys and there's so much parent guilt. Like, there's so much. I can't tell you how many parents have said to me, what did I do wrong? Like, when did I mess this up? Or like, what?

What?

Like, when do you think this started? Or like, what do you think I did? Was it something I did in pregnancy? Was it something I did? You know, I'm like, no, like, it's not. It's not that cut and dry and unfortunately. But as a parent, I get it because I've had the kid who has been the picky eater, who's, you know, 01% on the weight chart her whole first year, who struggled to feed breastfeeding. It was awful. And, you know, as much as I knew deep down it wasn't my fault, I still was like, I have one basic goal in life right now. This is keeping this baby alive. I got to keep her breathing and feeding like. And peeing, like, I got it, you know?

Yeah, yeah. And so totally get that. I have a. I have a kid. I, you know, she was small. We had to get induced because of preeclampsia, and it was a very traumatic birthday. And then it was like she was so tiny. Breastfeeding did not go well. Didn't happen. I exclusively pumped for nine months for her, and it was exhausting. And then, you know, did like, oh, I'm feeding specialist. She's going to be great. And she was feeding herself with utensils. And then we hit the picky eating phase and we're still in it four years later. And I'm just like, ah. So I get it, I get it. So just I think it's really important for any clinician just to be sensitive to that. And as much as you want to judge, I mean, a lot of times we get cases. And I'm like, the kid's not eating at school. And I asked the parent, I was like, do they eat with an iPad at home? And they're like, yep. And I was like, I hate to do it, but sometimes we get kids to eat if we get them access to electronics. It's not, it's not a long term fix, but it's like if we can get them eating successfully at school to keep them at school so they don't have to have a modified day, then maybe they need this accommodation for a little while until they can get used to the mealtime routine at school.

Yeah. So yeah, yeah. No, I like the flexibility in it. I think it, you know, more people need to hear that because I think people are so hard cut on, like, no, you don't do this and you don't do that. And it's really about like, well, what is the best thing for this child right now? And then how do we maybe adapt, you know, how do we adapt to the current needs? And then how do we phase maybe some of these crutches, you know, or supports out. Not a crutch, but supports out. So I mean, it definitely sounds like you do a lot of education with families for sure. I'm guessing you probably do a lot of education with school staff as well. Is that a big component of the program?

Yes, we definitely have like, our, our OT department is over 80, so we have over 200 schools in the county I work with. So yeah, we do a lot of education with them and a lot of it is building competency at the school base. So we are coming in as kind of like more seasoned, more experienced, I don't want to say expert because I work with some people who are just as talented as I am. I just happened to fall into being one of the leaders on this team. And so it's a lot of education and meeting the clinician where they're at. So there's some new clinicians, like, oh my gosh, I don't want to touch feeding. I'm so scared. Can you come out and see this kid with me? I'm like, sure. And then we'll share a lot about if I've in service, about my tool and that made that accessible to the entire department to use. And then speech and Physical therapy also do their throughout the year. So we have professional learning teams where we meet every so often and review any of the latest literature, send an email and say, hey, we don't need to have a meeting. But this is really cool information.

I love that. And I think that's so critical, so crucial, so needed. I mean, there's so many therapists out there, whether it be in the schools, because we get people who come to us and say, well, speed the Pete's.

Like, will it be for me?

I, you know, I'm in the schools and we tell them, like, look like you need to know this information. So yes, it's for you. How you deliver it in the schools might look very different than in a clinical setting, a medical clinical setting, you know, outside of like a educational setting. But we do tell people, you know, a lot, like, yes, it's beneficial. You need this information. It's very foundational. And so I love that you're also helping to kind of guide and educate these aspiring feeding therapists because, you know, there's so many of them that are out there and they want to do it, but they're so afraid.

I know. And, and that's one of that was, along with, you know, trying to fulfill that gap that I noticed in the research with my doctorate is I, I want to be an educator. And I am, I'm so motivated to inspire the next generation of OTs and feeding therapists. And so when the opportunity came to join the Feed the Peas, I'm like, yes, this is a, this is my, you know, this is a definite plus in my book because I just, I want to inspire and I want to help and guide and teach to the best of my ability.

Well, we are so excited again to have you on our Feed the Feeds team. And thank you again for joining us. Is there anything else you want to share before we start to wrap up today? Anything else you want to share about, like mealtimes at school?

Not that I can think of, but I'm sure there might be questions coming through, so feel free to reach out to me and be happy to talk with you. I do have a website. I don't know if that you could share that. I think I can share that with them. And mealsandschools.com.

Yeah, we'll put that in the show notes so everybody has access to that as well. Yeah, yeah.

And I may be doing like an informational session in the coming months when I can find some time.

Yeah.

About what? About what meals is about and about OT's role in the school setting with mealtime challenges.

Love that. Well thank you so much Karen for joining me today and again for joining the Feed the Peeds team. We love you. We're excited to have you and I'm excited. I'm excited for the future.

Me too. Thank you so much Allie Quick Disclaimer.

All information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Thanks for listening to this podcast. If you found value in this episode.

And want to hear more of these.

Myotots, Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts and share this episode on your social media platforms. You can access free resources and all I offer@halibalkin.com or pop over to hollybalken on Instagram to get all the latest updates.