Making Sense of Selective Eating - Ep 4
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[00:01:04] Madi Metcalf: Hello, welcome to making sense of selective eating, understanding the medical domain of PFD featuring Dr. Praveen Goday. My name is Madi Metcalf and I'm a speech language pathologist with an interest and passion for pediatric feeding disorders. I'll be your host for the speechtherapypd. com podcast mini series.
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[00:01:39] Now, without further delay, I would love to welcome Dr. Goday. Praveen Goday, MD, is a pediatric gastroenterologist at Nationwide Children's Hospital. He is the director of the Nutrition and Feeding Programs, which provide nutrition care throughout the hospital system and care to children with feeding disorders.
[00:01:55] feeding problems. He is a clinical professor of pediatrics at the Ohio State University. Dr. Goday is a graduate of Madras Medical College in India. He is a board certified in pediatric gastroenterology and nutrition. He is active at the national level in promoting pediatric nutrition. He is currently serving on the committee on nutrition of the American Academy of Pediatrics and the Board of the American Society for Parental and Internal Nutrition.
[00:02:21] He has been recognized by several societies for his work in pediatric nutrition and has received the Distinguished Nutrition Support Physician Service Award from ASPEN in 2018, the Master Educator Award for Sustained Educational Scholarship from the Pediatric From the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and Honorary Membership of the Academy of Nutrition and Dietetic, Dietetic, oh, sorry guys, my speech is a little tricky tonight, for distinguished contributions to the field of nutrition in 2022.
[00:02:54] Dr. Goday's research interests include multiple efforts to improve feeding, nutrition, and growth in children with diverse diseases. In 2019, Dr. Goday was the lead author of the paper that defined pediatric feeding disorder that has served to unify this common but understudied condition. This was followed by a paper that identified the prevalence of this condition.
[00:03:13] He has also co authored important publications such as the original paper that identified the key concepts of pediatric malnutrition and the guidelines for nutrition provision to critically ill children. He has also edited two books, Pediatric Critical Care Nutrition and Pediatric Nutrition for Dietitians.
[00:03:29] for joining us. Hello, Dr. Goday. I am so honored to have you on the podcast tonight. How are you doing? 
[00:03:36] Praveen Goday: I'm very well. Hello, and thank you for having me on this podcast. I'm delighted to be here and take and answer questions. 
[00:03:44] Madi Metcalf: Awesome. We are so excited. Whenever I got started in Pediatric feeding disorders.
[00:03:49] Your the article on the consensus of PFD was one of the first articles that I read that got me hooked and realizing the multidisciplinary nature of feeding. So your work has had a really big impact on my career working in PFD and I am honored to have you here tonight. So 
[00:04:08] Praveen Goday: Thank you. 
[00:04:09] Madi Metcalf: With that, Let's get started.
[00:04:11] So just for a recap of where we've been on this podcast series so far we had Stephanie Cohen the first week and she gave us an overview of PFD and talked about the four domains and kind of like a responsive feeding lens to treatment. Then we had on Oh, my goodness. I am blanking who we had on the second week, but last week we had Raquel Durban and we talked about like nutrition and the importance of being mindful of like the variety of food we're eating, how that's impacting our gut biome.
[00:04:39] In that kind of field related to the nutritional domain and week two was Lily Gullion she's an O. T. and talked about the O. T. 's role in feeding and how we can address feeding in the schools and so today we're going to be really jumping into that medical domain. So can you start off by telling us the importance of role or explaining the importance of rolling out the medical domain when working with selective eating?
[00:05:03] Praveen Goday: So I think the medical domain actually only consists of two different things. The first is almost exclusively confined to the NICU and to very little babies. So this is the cardiorespiratory changes that we see when a child is feeding, typically apnea and bradycardia spells or A and B spells. So those don't really occur outside of the NICU very often.
[00:05:31] The other piece that defines the medical domain is either aspiration or it's a sequelae. So if somebody is getting repeated aspiration pneumonias, then that is consistent with pediatric feeding disorder from a medical domain perspective. The important thing here is that there are a variety of diseases and disease states that are associated with pediatric feeding disorder, but they don't define BFD.
[00:06:02] The classic example is that of eosinophilic esophagitis, where some children do have BFD in addition. So, EOE is actually an association of Pediatric Feeding Disorder, but does not define PFD, if that makes sense. 
[00:06:22] Madi Metcalf: Yes. The more I get into PFD, it really kind of blows my mind because you can have EOE, or you can have autism, or you can have a number of things.
[00:06:32] That doesn't necessarily mean that you're going to have. a feeding disorder. 
[00:06:36] Praveen Goday: Correct, correct. So you need, you need something in one of these four domains that actually calls you out as having PFD. 
[00:06:46] Madi Metcalf: To get a PFD diagnosis, do you have to have something that gets triggered in more than one of the domains, or can you just have one?
[00:06:55] Praveen Goday: Just one domain, like a kid that aspirates, you kick it off when you're done. Well, so that That being said the difference between a picky eater and PFT is the fact that they don't have any dysfunction. So a picky eater shouldn't have medical dysfunction or skill based dysfunction, definitely, but they shouldn't have nutrition dysfunction.
[00:07:19] They don't eat a few things, but they're still getting a wide variety of things. And, and the trickiest part with picky eaters is that they drive their parents crazy, but they should be. within limits such that it doesn't trigger the psychological domain. If that makes sense. 
[00:07:38] Madi Metcalf: Absolutely. Yeah, that was one of the reasons I named the podcast Making Sense of Selective Eating because I feel as a speech pathologist, one of the, you know, I have kids that get referred to me because they're aspirating or there's, you know, significant things going on with feeding skill, but a lot of times when I get a feeding kiddo on my caseload, the primary concern is selective eating.
[00:07:59] And so how this podcast, I really wanted to kind of dive in and explore, like, One of the first topics we talked about was typical selective eating versus atypical selective eating and kind of where that falls and then realizing that, you know, if you have a selective eater, you can't just look at them at the surface and say, okay, well, this kid's picky.
[00:08:18] We need to Do this or, you know, you kind of have to take that step back and really assess that full picture and make sure that there's not a medical concern going on or a psychosocial you kind of have to dig a little bit deeper than just saying, Oh, well, they're picky. 
[00:08:34] Praveen Goday: Correct. That's absolutely true.
[00:08:35] I think, I think from a nutritional perspective, though, we are not going to talk about that. It's important that the child takes foods from all of the food groups. And that's an easy way for feeding therapists to, to figure out if there are likely to be any major nutrient deficiencies. And and the, the two food groups that can kind of substitute for each other are fruits and vegetables.
[00:09:01] So, you know, as a tomato, actually a flu or a vegetable, I mean...
[00:09:05] Madi Metcalf: mm-Hmm...
[00:09:05] Praveen Goday: they, they kind of provide the same nutrients. So as long as a kid is eating from all five food groups, then from a nutrient deficiency perspective, that's gonna be far less common. 
[00:09:18] Madi Metcalf: Okay. So... 
[00:09:19] Praveen Goday: keep in mind. 
[00:09:20] Madi Metcalf: So if I have a kiddo that's eating a pretty robust diet of a lot of fruits, but they don't eat any vegetables, you can kind of say, okay, they're probably getting enough of those nutrients from the fruits.
[00:09:29] Praveen Goday: Right. Absolutely. 
[00:09:30] Madi Metcalf: Okay. That is very interesting to kind of take into consideration. 
[00:09:36] Praveen Goday: Right. Because, because the difference between fruits and vegetables are somewhat arbitrary. 
[00:09:41] Madi Metcalf: Hmm. Okay. So interesting. And also a little bit of a sigh of relief because I have a lot of kids. It's easy to get us to kind of explore and adventure into fruits, but vegetables can be a little bit more tricky sometimes.
[00:09:55] Praveen Goday: Correct. Vegetables tend to have a little bit of bitterness to them and it's much harder for, to convince picky eating kids or selective eating kids to eat them. 
[00:10:07] Madi Metcalf: Such a good little thing to kind of keep in the back of our minds as we're working with our patients. So can you talk a little bit about how GI disorders can lead to selective eating?
[00:10:18] Praveen Goday: So I think, I think the poster child is eosinophilic esophagitis, and eosinophilic esophagitis for those that are not familiar with this is a condition that I, I kind of tell my patients is like asthma of the food pipe. It is not, but that's a, that's a way for people to understand. It definitely seems to be associated with food allergies and the commonest food allergy that it is associated with is of cow's milk.
[00:10:45] That does not mean that it is cow's milk alone. Some children need many things eliminated from their diet before their EOE will respond. So we think that EOE affects the musculature of the esophagus and causes food to not move down correctly or in a painful manner and that causes children not to want to eat.
[00:11:07] This is speculation because it happens in the youngest children and they really cannot describe to us what's going on in their lives. 
[00:11:15] So, and just treating EOE doesn't make it go away because these children have not really learned to eat properly. So they need therapy on top of treatment in order to get better.
[00:11:31] That's the commonest cause of. of a GI disease causing or influencing a feeding disorder. 
[00:11:40] Madi Metcalf: How do you diagnose EOE? 
[00:11:42] Praveen Goday: EOE requires an endoscopy. So you cannot do it without an endoscopy. At the present time, there are no blood tests that can tell us that somebody has EOE. We need an endoscopy and we need biopsies from at least two parts of the esophagus.
[00:11:56] And these biopsies should have more than X number of eosinophils in each part to be able to make the diagnosis of EOE. 
[00:12:05] Madi Metcalf: What are some red flags that therapists should look out for whenever we are assessing a kiddo? And EOE might be a factor. 
[00:12:15] Praveen Goday: So the, the things that are when a child has other food allergies, so children with food allergies are much more likely to have EOE.
[00:12:23] That's one. The second is when a child has had a milk allergy in the past, especially as a baby and has outgrown it. That is another red flag. The third red flag is of other. Allergic conditions such as asthma or eczema, or if there's a family history of these conditions. And finally, occasionally we see parents with EOE now having children with it.
[00:12:48] So those are the red flags. The other thing is in every, any child who has BFD who also has vomiting, we need to think about whether EOE could be involved. 
[00:13:00] Madi Metcalf: Okay. good things to kind of be on the lookout for. 
[00:13:06] Praveen Goday: The other, the other crazy thing is that, it seems like kids with autism are more likely to have you.
[00:13:14] So, this was in a database based study. So we don't know if that's necessarily true, but we see it in real life too. We see lots of children with autism and the general thinking is that, The child has autism and so has a feeding disorder, but then nothing prevents the child from having more than one condition.
[00:13:33] And sometimes kids with autism also have.
[00:13:37] Madi Metcalf: So it's one of my inclinations to whenever I'm have a kiddo that I'm assessing for pediatric feeding. And I find out that they have like low volume intake. I usually want to refer to GI just to check that box. Is there, I guess my question is, like, how do you know if you're over referring to GI or not whenever you're doing a feeding evaluation?
[00:14:03] Praveen Goday: I think the real problem is any child with PFT can have EOE. And we are stuck thinking about it all of the time. So for me, the question is whom do I scope, right? For you, a referral means, yes, the child has to come to GI. It's a pain for the parents, but there's no real adverse effects or anything.
[00:14:31] Nobody's doing anything invasive. But for me, it's the next step. Do I scope every kid that I see with BFD? And Absolutely not. You know, there are lots of children with PFT and I'm not going to scope everyone, but if they have these high risk factors, then I definitely do scope them. The other thing I tell families is if I have a kid with PFT who's undergoing another test under, under anesthesia, then I'd like to scope them at the same time.
[00:15:00] Madi Metcalf: So you're kind of. One and done. They're already going under. Let's just double check. 
[00:15:05] Praveen Goday: Correct. That's something that I will do. The last thing is, if they're going to undergo an intensive feeding program, then I will also scope them at the scope them prior to the intensive feeding program. And we found kids who had no red flags and ended up having EOE prior to the Wow.
[00:15:22] If that's a program. 
[00:15:24] Madi Metcalf: Wow, that is pretty wild that they weren't having any symptoms, but then they were, 
[00:15:30] Praveen Goday: well, they had PFD, but outside of that, they didn't meet all of those things that we talked about, you know? And so that's what is in a way a little bit frightening, right? Like whom do I scope? 
[00:15:42] Madi Metcalf: Yeah. 
[00:15:44] Praveen Goday: So I will never fault you for referring to GI, unfortunately, or fortunately, whatever.
[00:15:50] Okay. 
[00:15:51] Madi Metcalf: Makes me feel a little bit better because I always tell my parents, I'm like, you know, maybe there's nothing going on and we are just kind of sitting here in this like feeding skill and psychosocial kind of domains. And that's what we need to work through. But the way that I feel is I'm like, if I'm, you know, Working with this kiddo on eating and their body's telling them this doesn't feel good.
[00:16:13] I don't feel safe eating. This isn't uncomfortable What is that gonna do to my you know relationship with that child if if like they associate You know, the things that I'm doing with hurting them more because they don't have the skill to tell me they don't have that diagnosis or like, I had a girl on my caseload that we referred to GI and she ended up having celiac and then the whole family got tested for celiac and the oldest daughter said she tested positive and they said, Oh, my goodness.
[00:16:42] Your stomach's not going to hurt anymore. And she said, your stomach's not supposed to feel like this. Like she had no idea that what she was experiencing was abnormal. It was just her normal. 
[00:16:52] Praveen Goday: Correct. So with young children, that's frequently the case, because they don't know what it is to feel well. So they always think that that's how life is meant to be.
[00:17:02] Madi Metcalf: Oh, that just breaks my heart. Those poor, poor kids. 
[00:17:05] Praveen Goday: It is. So the other big GI condition that feeding therapists frequently refer to is is GERD, or reflux. And, honestly, there are no data out there that suggests that GERD causes GERD. And so I can tell you that I've almost never seen a child that purely had good and had a feeding disorder.
[00:17:31] One, when, when one, one is thinking of causal relationships, one is thinking if you made it better than the, then the feeding disorder should get better. Occasionally we do see kids with significant vomiting who then respond to an acid blocker potentially it is reflux. But outside of that, I don't really think the garden variety PFT that you and I see in our clinics is related to that.
[00:17:59] Madi Metcalf: Okay. So it might just be an unpleasant symptom that they're experiencing. 
[00:18:04] Praveen Goday: Well, it's hard to diagnose GERD. You actually need a pH probe or a pH impedance probe. We very rarely do that. So we typically give a kid an acid blocker and see if they respond. And then we presume it's good, right? Because there's no simple test.
[00:18:21] Again, you've got to see if you're, putting out more acid over a 16, 20, 24 hour period. And so because of that, most of us don't do the test. But that being said, most children do not respond to acid blockade all the way from itty bitty babies to older children. 
[00:18:42] Madi Metcalf: They do not respond to them? 
[00:18:44] Praveen Goday: No, by eating a lot more.
[00:18:46] No, that's, it's very uncommon. 
[00:18:49] Madi Metcalf: Gotcha. What about management for constipation? Cause I feel like that impacts some of my eaters sometimes. 
[00:18:59] Praveen Goday: I think constipation is an important co occurring condition. And the way, well, If one thinks back to one's own life and a time when you haven't pooped for a while, the last thing you want to do in life is to eat.
[00:19:14] So I feel like if you keep the bottom end empty, then kids are much more likely to eat. And I find that when kids are being treated for PFT, if you take care of their constipation, their PFT improves a wee bit. Kids eat better on the days that they've pooped than the days that they haven't pooped. 
[00:19:35] Madi Metcalf: Is it okay to And you, I, I want to ask that question.
[00:19:39] Never mind. Well, actually, I will. Is MiraLax and other laxative type medications the only way to treat constipation? Or is there kind of like a root cause or something deeper you can do to kind of address the constipation? 
[00:19:53] Praveen Goday: 95 plus percent of constipation is It's what is called functional constipation.
[00:19:58] At one point the kid has a really hard stool and then they decide pooping is painful and they start withholding, which is squishing their butt together and preventing poop from coming out. This then becomes a vicious cycle because the kid eventually has to poop and then it hurts as though the child is having a baby and then, and then the brain says it hurts to poop and goes round and round.
[00:20:20] So we need to break the cycle. There are at least a couple of studies which show that just adding fiber or adding fluid does not seem to help the constipation. The other issue is when you're talking about a PFT, the last thing you're trying to do is trying to manipulate this using the diet because the kid is already not eating many of the things that you want them to eat.
[00:20:42] So it is best to use a medication that will take care of the constipation. And if a kid will take Miralax mixed with whatever, then that's fine. But otherwise we have to be more innovative and try and get the kid to take whatever medicine he or she needs. 
[00:20:59] Madi Metcalf: Gotcha. That makes so much sense. And I had no idea that, was it 95 percent is functional?
[00:21:04] Praveen Goday: Yeah, it's probably even higher, but yeah, most kids, most kids. Yes. 
[00:21:08] Madi Metcalf: So interesting. And also makes a lot of sense reflecting on my own childhood. Can you talk a little bit how Well, I guess we've already touched on it a little bit, but is there any more that you'd like to share on like how GI disorders can impact selective eating?
[00:21:21] So we talked about constipation. If you don't feel good, you don't want to eat and same with like EOE, if your throat's hurting or if it's hurting to swallow food because your esophagus is really inflamed, that's also going to cause, you know, discomfort and restriction. But is there any other ways that GI disorders can impact that?
[00:21:36] Praveen Goday: So they don't really affect selective eating. They can affect appetite as a whole. But that's true of any disease, right? You feel lousy, you don't want to eat. So all GI diseases tend to decrease appetite. I mean, I'm generalizing and being but if you feel bad, you're going to eat less, but they don't typically cause selective eating per se.
[00:22:00] Madi Metcalf: Okay, so that's a good way to think about it, because sometimes I, in my head, I can be a little black and white. And so it's like, okay, so when I'm looking at my PFD graphic with like, PFD in the middle, we have the four domains kind of circling it. I'm like, okay, so what was the cause? Where's the one thing that we can kind of point to, but it's really a culmination of all those factors that leads to the PFD.
[00:22:27] Okay. 
[00:22:27] Praveen Goday: Correct. Yes. And then there's also low appetite, PFD, which we don't really understand. The kid just doesn't want to eat. And sometimes it's due to medications that have decreased appetite, typically stimulant medications. These are not things that feeding therapists see because these kids don't have feeding skill problems, but we don't understand why some kids just don't have appetite and that can be very difficult to treat.
[00:22:57] Madi Metcalf: Does that kind of fall into that Avoidant Restrictive Food Intake Disorder or ARFID? 
[00:23:02] Praveen Goday: Potentially. Now there's a minefield about what is ARFID and what is PMD. So the way I think about ARFID is that it is basically the psychological domain and it causes nutritional It causes problems in the nutritional domain.
[00:23:21] So that's the way I think about it. I think the medical domain and the feeding skill domain have to be left out. But if you talk to five different people, you'll get five different answers. And some people call everything ARFID and some people call everything BFD. 
[00:23:36] Madi Metcalf: It's definitely really interesting. And I feel like there's more traction with ARFID with Just like the general public, I've had several patients in the last six months that have come to me and the parents have been like, I think I have, my child has ARFID and so it's not just the providers that are being told that like the parents are coming across this and then bringing that into their feeding evaluations.
[00:24:02] And that's been really interesting and tricky to navigate. Especially after listening in, I attended the feeding matters conference this spring and there was that consortium over ARFID and PFD and it was really interesting listening to that panel kind of talk about the distinction and the overlap and just how all of that kind of fits into place.
[00:24:25] Praveen Goday: Right. I think ARFID started out predominantly as a psychological diagnosis. It was in the DSM 5 and then it's taken on a life of its own. So the, it, it primarily, in my mind, should be used in older children without feeding skill deficits. Who primarily have psychological issues, and among the psychological issues, anxiety.
[00:24:50] Outside of that, it doesn't have very much of a role, but even kids with ARFID or true ARFID should undergo an evaluation to make sure that they don't have medical issues or feeding skill related issues, because some of these kids will. 
[00:25:03] Madi Metcalf: I, two of the kids that came to me and parents were like, I think we're dealing with ARFID.
[00:25:09] Getting into the evaluation, both of them had significant GI concerns with stooling, stomach pain, bloating, discomfort, gassiness, and I was like, okay, let's dig into this a little bit more. Maybe our body doesn't feel good. And we're not, we actually like, don't have an appetite for this reason. Not some. I just don't want to eat.
[00:25:28] But. And one of the, one of my patients got the PF or the ARFA diagnosis without having a formal feeding evaluation to look into medical and feeding skill deficits that could be present. So definitely really interesting. And if any of our listeners are. More curious about this feeding matters. I believe it's at the end of August is having a I think they're calling it a psych summit talking about ARFID and PFD and how that overlaps and just kind of getting more consensus in the field about when we use which diagnosis and how that fits into PFD or how they exist side by side.
[00:26:07] Praveen Goday: Right, right. How they exist side by side is, is I think there's a need for an alpha diagnosis, but I think, I think if you take care of kids with feeding skill related problems, that's not offered. 
[00:26:21] Madi Metcalf: That is a really interesting way to put that. Can, or can GI disorders impact overall nutrition of a child?
[00:26:32] Praveen Goday: Absolutely. Well, there are so many GI disorders, right? So start with the stomach all the way down to the colon. And the the role of the GI tract is to absorb water and various nutrients and nourish the body. So if parts of the GI tract are not working, you're going to end up with nutrition problems.
[00:26:52] It's as simple as that. 
[00:26:55] Madi Metcalf: The word EOE cause, Other than limiting your intake, would it cause nutrition problems like with absorption? 
[00:27:02] Praveen Goday: No, it does not because it just affects the esophagus. So the esophagus is not involved in actually assimilation of nutrients. It's basically a tube, right? That causes food to pass through.
[00:27:15] And so the primary reason that EOE is associated with all of these problems is because you don't consume the food that you're supposed to. 
[00:27:25] Madi Metcalf: Gotcha. A disorder that I have heard about, but I haven't experienced firsthand with any patients is delayed gastric emptying. Can you explain a little bit about what that is?
[00:27:38] Praveen Goday: So delayed, it basically means the stomach takes longer to empty. 
[00:27:42] Madi Metcalf: Okay. 
[00:27:43] Praveen Goday: So when we eat food there is a particular cadence. So within a certain amount of time, your stomach should be empty so you can eat your next meal. If you have delayed gastric emptying, it means quite simplistically that the food sits in the stomach.
[00:28:01] And since it sits in the stomach, it is either available for puking out because it just stays there and irritates and then you puke it out, or it sits there and therefore you don't feel like you need to eat again. So that's how it affects your, your nutrition. And. While the stomach can absorb some nutrients, most nutrients have to be absorbed in the intestines.
[00:28:23] So the food has to get to the small bowel in order for it to actually do its job. So that's how people suffer. The issue is while delayed gastric emptying does exist, it is a common finding in a lot of older children who have other functional problems, such as Belly pain and constipation and things like that.
[00:28:50] So, we have to be careful about over diagnosing kids with delayed gastric emptying. 
[00:28:58] Madi Metcalf: Is there a diagnostic test that can be like, use like a scope can for EOE to say like, okay, we are definitely dealing with delayed gastric emptying? 
[00:29:07] Praveen Goday: There is a test. It's called a gastric emptying scan, but it is based on a child consuming a specific diet over a specified period of time.
[00:29:18] So in kids with PFD many of those kids won't eat the toast and the eggs. The, the radioactive substance has to be cooked into the eggs. So you have to actually eat it as is and many children will not be able to eat it. So we are not able to do the test. The other problem is that the test is not that great.
[00:29:43] And when they tested adults who had delayed gastric emptying over a period of three years, they tested them every quarter or every six months. They went in and out from delayed to normal to delayed to normal. So the test is not a great. 
[00:30:00] Madi Metcalf: Gotcha. How can GI disorders impact weight loss and weight gain?
[00:30:08] Praveen Goday: Again, again, because it is a nutrition issue, right? Like, if you are not absorbing, if you're not eating and absorbing all the nutrients you need, you're going to lose weight. So that's why many GI disorders are associated with weight loss. Weight gain is a totally different kettle of fish. And I think that's a societal problem more than a medical issue as such.
[00:30:37] But that being said, not everything seems to be medical for, for example, a microbiome plays a role in weight gain as well. Some people have microbes that seem to Suck up the energy that's in the colon and pass it on to the human being and those people can gain more calories from the same diet as opposed to a thin person.
[00:31:02] I don't know if you've heard of the person who got a stool transplant from a fat person and this person was thin and the thin person then became fat because of the area that was transferred. So the way it works is the fiber that we eat goes to the colon and feeds the bugs in our colon, which is good for them.
[00:31:25] But each of us has our own microbiome. And some of us are, some of our bugs are better at converting those into calories and then pushing it to us. 
[00:31:35] So even if you and I eat the same hundred calories and you have a microbiome that's thin and minus fat, then I'm going to get fat on the same calories while you're going to remain thin.
[00:31:47] If that makes sense. 
[00:31:48] Madi Metcalf: That is so interesting. I did not know that. And it just gets me, I don't know, it kind of gets my wheels turning a little bit. I think, you know, how did I can think of one patient at my clinic and they are on the overweight side, but they only eat a handful of foods but they eat, you know, the same cereals, chips and crackers that my super underweight kiddo eats and, you know, that's been, I don't know, I've thought a lot about that and I'm like, how do you have such a restrictive diet?
[00:32:24] diet, but you're on complete opposite ends of the spectrum. Which of course I'm not entirely sure like volume that he's eating compared to the girl. 
[00:32:30] Praveen Goday: That's the issue. So I wouldn't blame the microbiome for everything. It's, this is just an anecdotal thing. It probably plays a role, but most of us, Not most of us, but many kids with BFD will eat highly nutrient dense foods, which are low in nutrients.
[00:32:48] So I mean, they, you, calorie dense foods that are low in nutrients. So when you eat, when you eat five chicken nuggets, right, those are, I don't know, I'm going to say 200 calories, but then they don't have any vitamins or minerals or anything that's good for you. So that's the issue. 
[00:33:05] Madi Metcalf: So we've kind of touched on this with EOE and a little bit with you, we can't over refer, but do you have any other major red flags of these are some pretty big things you should look out for and refer to GI if you're seeing them on in your PFD kiddos.
[00:33:22] Praveen Goday: I think vomiting is a big one. 
[00:33:24] I think that's the biggest one that I would think about then kids who don't Eat all of the things that they're supposed to which is from a food group perspective So if you look at grains meats fruits and vegetables as one group and dairy Then if they don't meet all of these they either need to see a dietitian and orgy So clearly if they're malnourished, I don't know if feeding Specialists are in the business Of looking at malnutrition, but malnourished children with PFT should be seen by somebody else so that their malnutrition can be treated.
[00:34:01] Madi Metcalf: That is one thing that I worry about with some of my kiddos. Whenever I see their diet, I'm like, are we meeting all those micro nutrients in our diets to make sure that we're healthy people? And I sometimes find, I can usually get a parent on board with a GI referral, but I have a harder time getting them on board with like a dietician referral.
[00:34:26] And I haven't figured out how to like get that pieces being important also just to kind of get that. You know, support and figuring out where we need to expand more into different nutrients like last week Raquel Durbin shared that, you know, she can look at a diet panel and she can kind of help come up with, okay, we should maybe work towards this food group or that food group or these types of foods to make sure that we're kind of filling in these gaps versus me just kind of, you know, Choosing where we go or talking to the family like it can be more of like that team and have more of a of a goal in mind to treat more holistically if we use that team approach and collaborating with that dietitian.
[00:35:13] Praveen Goday: So, 1 of the things is it also depends on where you live and practice. Because in some areas, a dietitian may be easier to get into than a pediatric gastroenterologist. So, that's something that is completely dependent on local factors. And if you can get some, well, I'm not saying everybody should go to a dietitian or everybody should go to a PGI, but you know, sometimes that might guide where you send your patients to.
[00:35:41] The, the second thing is it is absolutely useful to say, okay, this is what we should push for next, but that's in selective eaters without weight issues. Okay. Oftentimes we see low appetite and selective eating. And so we have a malnourished kid who's also selectively eating. In many of those kids, we end up pushing a high energy beverage, you know, sort of in the pediatric boost kind of range.
[00:36:10] So that sort of you kill two birds with one stone, trying to get them to get more energy, protein and fat, but you're also getting micronutrients.
[00:36:20] Madi Metcalf: Is that, so GI or a dietician could recommend and prescribe the nutritional shake or high energy beverage? 
[00:36:30] Praveen Goday: Yes and no. They can prescribe the ones that are over the counter. So if you're going to get stuff that the family is going to pay for, then yes. But once you need WIC or you need, you need to hit on the insurance, then the dietician is going to need some sort of medical provider that will stand on his or her side.
[00:36:55] Madi Metcalf: Okay. So in that case, you would need like a GI or a PCP to come in. 
[00:37:01] Praveen Goday: Correct. Correct. Somebody, somebody. So the dietician, especially if a dietician is working on her or his own, then they should know whom they would lean on to get that accomplished. 
[00:37:14] Madi Metcalf: Okay. So at Nationwide, you guys have a multidisciplinary intensive feeding clinic, correct?
[00:37:21] Praveen Goday: Yes, we do. 
[00:37:22] Madi Metcalf: Could you share a little bit about your program there and what an intensive feeding program looks like in kind of that interdisciplinary nature that you guys are able to provide? Use there? 
[00:37:32] Praveen Goday: Yes. So, every child that walks in through the door gets an evaluation that consists of all of the disciplines.
[00:37:39] So by that I mean medical. And then we have a feeding therapist either in the form of an SLP or an ot. We have a dietician, we have a psychologist we have nurses as well as a social worker. The evaluation then then determines what needs to be done with regard to the child from an outpatient perspective.
[00:38:01] We then sometimes will follow the child and figure out things that can be done on an outpatient basis and the child sometimes improves with just that and that's it for the child. The child does well, we discharge the child. Some other children need more intensive forms of therapy. So we now have a couple of programs.
[00:38:23] One is the co treatment program. The co treatment program consists of a behavioral psychologist as well as a, as a feeding specialist, in this case now an SLP. And the two of them work together. They see the child once a week for about eight weeks. This can jumpstart some of the things, but is. Not meant as a cure or any of cure of problems.
[00:38:48] The intensive part of our program is an intensive outpatient program. It is eight weeks long and it's Monday through Friday. It's roughly 8 a. m. to 4 p. m. It's three meals a day. In the program. So kids either come from home if they live close by and but they spend the 8 a. m. to 4 p. m. around, you know, in the program or they live in a McDonald house.
[00:39:14] They come from far away. 
[00:39:16] Madi Metcalf: Is there a kind of like a standard flow to the day when they're there from 8 to 4? Or does it vary? 
[00:39:23] Praveen Goday: Three meals. So there are we have multiple teams and they, there's an early feeder and a late feeder for each team. So you either are at the 8 a. m. slot or the 9 a. m.
[00:39:35] slot, and then you get fed every three hourly, give or take. 
[00:39:39] Madi Metcalf: Okay. 
[00:39:39] Praveen Goday: And then there's time for naps for little kids and the whole nine yards. 
[00:39:44] Madi Metcalf: Is the day kind of broken up with like fun activities and things like that as well or is it all kind of therapeutically focused? 
[00:39:51] Praveen Goday: No, the, well, firstly, babies do have to rest, not babies, but little ones, right?
[00:39:56] If you're under the age of three or four, you probably nap during the afternoon and stuff. There used to be a lot more interaction between the kids until COVID and this was before I joined the program. Right now we're trying to get. To that, but, you know, we are, we are somewhere halfway to that. There is, there is a play room slash library slash family room where families can gather we do have a child life specialist in the form of a music therapist and things like that So that's that's how the day goes, but it's it's pretty busy because there are three meals and a nap and And kids need some downtime to, 
[00:40:38] Madi Metcalf: You implement parent coaching and kind of guide the parents and how to better feed their kiddos and support them at home in the program as well.
[00:40:48] Praveen Goday: Yes. So, I think all feeding programs ultimately are parent coaching programs, right? 
[00:40:55] So basically, basically in the beginning, we, in, in our, in our program, the, the feeding therapist is the primary feeder. The psychologist is, is a watcher and tweaker of things. So typically it starts out with the parent being behind the glass and the feeding therapist learns how to feed the child and then the, the positions are swapped.
[00:41:22] So that's what happens in our program. And when and where that happens depends on the individual child. 
[00:41:28] Madi Metcalf: Gotcha. Can you explain what your working relationship is since this is a predominantly like SLP population that we're speaking to tonight? Can you kind of explain what your role is that you've been working with?
[00:41:41] Or your relationship with SLPs that you've had in the past working with kids with PFD. 
[00:41:48] Praveen Goday: So I hope I've had a good and close relationship with many of them. I let them be the experts of their domain and we work together closely to determine what are the aspects that need to be changed. For example, I lean on an SLP to decide if a child needs a video swallow study.
[00:42:09] I almost never will order one on my own. I mean, clearly there are some children, you know that they're likely aspirating and you go straight for it. But, but in the vast majority of cases, I will lean heavily on a feeding therapist to be able to make that decision. And then I follow their recommendations with regard to texture manipulation and things like that.
[00:42:34] So, yeah, 
[00:42:36] Madi Metcalf: What role do appetite stimulants play in PFD? 
[00:42:43] Praveen Goday: I think. They, they play, they play a very important role. And when we see kids with low appetite, it's one of the things we do. So, there's practically just one appetite stimulant, and that's the briapidemoperiactin. There are a couple of others, but they are very rarely used.
[00:43:02] The issue with the private Dean is that it almost always works in the beginning, and then it almost always stops working. So, initially you can try it all the time, and then you can use it on and off. give drug holidays. Some people will use it Monday through Friday and keep the child off Saturday and Sunday.
[00:43:25] Some people will use it two weeks on, one week off, things like that, variety of methods. And then it seems like you use it all the time. It stops working. You try it on and off. It works for a little while. And then six months or a year later, it just stops working. The other problem is even though the biggest side effect is supposed to be of sleepiness and tiredness, you almost never see that.
[00:43:48] What you see is the opposite. Some kids become really crabby and moody and angry, and so you have to stop it. Some parents will tell you there's no way they're going to protect you from seborrheic diabetes because of that behavior. 
[00:44:02] Madi Metcalf: Interesting. 
[00:44:02] Praveen Goday: So, the other thing is, it is primarily useful in low appetite kids.
[00:44:08] It is not useful in selective eaters whose appetites are okay, never ignored in the diet. It just makes the child eat more of whatever he or she used to eat. 
[00:44:20] Madi Metcalf: So you'd most likely see superheptadine used in a kiddo that has low weight and just not eating a lot of volume, even of their preferred foods.
[00:44:29] Praveen Goday: Correct. Correct. 
[00:44:30] Madi Metcalf: Okay. 
[00:44:31] Praveen Goday: And also, I also tend to use it at a time when I think it is most likely to be helpful. Sometimes I will use it right before the intensive program. So things like that. So I, I know that it's going to not, not work all the time, so I will use it kind of selectively. 
[00:44:49] Madi Metcalf: And so superheptadine is not going to be a long term solution, but just kind of a short term to kind of get things moving in a positive direction, kind of?
[00:45:00] Praveen Goday: Correct. The other thing that is very helpful is when kids are grazing, doing all that stuff. And when you tell parents you want the kid to eat only every three hourly in the high chair and all that kind of stuff, you want them to see the returns right away. Otherwise they're going to give up. So I find that using the double whammy of restricting the food to every three hourly, but using subcutane at the same time to improve the appetite convinces the parent that they're doing the right thing.
[00:45:32] Madi Metcalf: Oh, okay. That is just... 
[00:45:35] Praveen Goday: it's just a trick. 
[00:45:37] Madi Metcalf: Yeah, I have a kid on my caseload right now. I got diagnosed with ARFID when he was under two years of age. And 
[00:45:46] Praveen Goday: yes, 
[00:45:49] Madi Metcalf: we have like, he never wanted to eat growing up. He started self limiting milk at one month, found out at a year that he had a cow's milk allergy, but had been exposed to cow's milk his whole first year, severe eczema.
[00:46:03] They put him in a behavioral feeding program, I think before he got the milk. Allergy diagnosed and it was like during this process that he got ARFID diagnosed because he just wasn't interested in eating and so 
[00:46:17] We are currently they just moved to my state, Earlier this year and so we're i'm working with my local Gi And we are seeing if we can he's trying to get his hands on the original Scope report so that he can review it for himself.
[00:46:34] And then if he's not pleased, we're going to do an additional scope, but he wants to make sure that we don't, you know, if there's, if we don't have to do it, he doesn't want to. 
[00:46:43] Praveen Goday: Right. I understand that. 
[00:46:46] Madi Metcalf: But we are on superheptadine. And like you said, it works a little bit and then it doesn't. So we're currently doing an on off cycle with this kiddo and by we, I mean, his GI made that decision and I'm helping parents coach through that in my SLP feeding domain or feeding skill domain.
[00:47:07] But I was really wanting to get them on that schedule where they do every, you know, three hours and put a little bit more restriction to kind of limit that grazing and see if we can increase his appetite at those mealtimes. But the tricky thing is that this mom. Whenever he's on the super heptadine, he's asking for food for the first time.
[00:47:24] And mom wants to develop that positive relationship and positive feelings around feeding. And oh my gosh, my kid wants to eat. Let me let him eat. He's asking for it. He's never done that before. But then we get into this just kind of grazing all day pattern. And so I'm going to kind of take this to her and be like, Hey, listen.
[00:47:43] Because we've been on a two, I don't know if we're doing two or three week pause, but we've been on a two or three week pause. And then we're going to start back. I think next week we'll be back on the super hefty. I'm going to tell her, all right, mom, here's our game plan. We're going to capitalize on the super heptadiene and we're going to really try to hold off for three hours.
[00:48:02] Even if he's asking for food, we'll remind him he's going to get it so soon and kind of get into a little bit more of a routine. 
[00:48:08] Praveen Goday: Absolutely. 
[00:48:09] Madi Metcalf: That is just a great idea to kind of like using that as a tool to get you to your goals instead of just kind of we're eating, let's stay here, which is the goal, but we want to create healthy routines around feeding as well.
[00:48:26] Yes. Let's see. See, and if anybody has any questions, we're kind of getting into that Q and a point. So feel free to ask any questions that you might be having. What do you wish more SLPs knew about working with pediatric feeding disorders? And yeah, just overall, 
[00:48:49] Praveen Goday: I think, I think it's important to know the other domains. So I think, I think the medical domain is not very difficult because SLPs are quite familiar with aspiration. And the other one is just NICU babies and most SLPs out in the community are not seeing NICU babies.
[00:49:08] So I think, I think the key is knowing a little bit more about the nutrition domain and knowing the psychosocial domain as well is important. Also not to, not to blame reflux for everything. It's unlikely to be aware of EOE though. I think EOE awareness has spread quite a So I think, I think those would be the things that I would think about I, I also find that if we are in our own lanes, we sometimes, we sometimes want to get our domain to the top, right?
[00:49:47] Like in the sense that when a child is not growing particularly well and is eating three vegetables, it's not important that the child eats seven vegetables, but drink is high calorie milk so that his weight is okay. You know, he's not going to forget to eat those three, but getting him to seven is not that important.
[00:50:07] So pushing for variety when low volume is a problem is something that they should be cognizant of. And work with the rest of the team. It's much easier for me because all my peeps are in this under the same roof. So we talk every day, right? Whereas when you work on your own, then people are elsewhere and different people may have different viewpoints.
[00:50:31] And so it's important to figure out what everybody's trying to achieve. 
[00:50:37] Madi Metcalf: That's been one thing that's been so eyeopening. So on the podcast so far, we've had an SLP and OT I'm a nutritionist, a nutritionist nutrition or a dietitian and now a gastro and talk in a gastroenterologist. And one of the most eyeopening things that's been for me is that every person that's been on hasn't just talked about their domain.
[00:50:57] There has been significant overlap into the other domains as they're speaking about their role. And so today we talked so much about like that nutritional domain and how your medical issues can impact nutrition and that feeding skill might also be. Needing to take into consideration and your negative experience that you've had with your medical condition might lead to some impacts in that psychosocial domain.
[00:51:23] And so it really does take that interprofessional education and learning from the other people that are involved in P. F. D. because 1 domain and sit there and think we're treating. A pediatric feeding disorder. It really takes that. Interdisciplinary collaboration to effectively treat a pediatric feeding disorder.
[00:51:46] Praveen Goday: Right. Yes, absolutely. And there's a reason that there are four domains and we need to push the pawns in each domain to get to where we need to get to. So, and we can't, we can't ignore one of the domains. 
[00:52:00] Madi Metcalf: Yeah, 
[00:52:01] I, so I am in an outpatient community clinic in my area and I don't have any OTs or PTs that I work directly with.
[00:52:15] We are just speech therapists and It does take a little bit of extra effort to write those emails to make those phone calls to write those referral letters or specialist community. I call my specialist communication letter that I will type up and be like, Hi, this is what we're working on. Here's what we're doing in therapy.
[00:52:34] These are my concerns. These are parents concerns. And then I'll send that with them to their doctor's visit. And I'll write that letter in their session because, you know, It's part of that care. I'm talking about the letter with the parent to kind of make sure that we're all on the same page because that's the other important piece.
[00:52:51] I love that you talked about how every feeding program should be a parent coaching program. Because not only do we need to look at the four domains and like the dietician is in the feed or the dieticians of the nutrition domain the OT and SLP will be in the feeding skill, the psychologist and the psychosocial and then your GI, your ENT, whoever's managing whatever medical disorder you have going on, but like, there's also the parent and the parent is a key member to that feeding team as well.
[00:53:25] Praveen Goday: All right. Yes. Yes, absolutely. Absolutely. Yeah. When I get when I get messages from FMPs or from other specialists, I, I copy their message and put it in my little in a place in the patient's chart that only I can see so that the next time the patient comes in, I have that question in front of me because I don't remember everything about every child.
[00:53:47] And it has to be at the next visit that I address that. So then I address it To that person as well as the parent and take care of it. So that's what I do. 
[00:53:56] Madi Metcalf: I am super thankful. I get to see my parents, you know, weekly with my patients and so we're able to knock out a lot in our session sometimes and sometimes it kind of shocks me how much of a feeding session Like yes, I'm working with the kid.
[00:54:12] We're doing some feeding. We're working on placement with feeding work on that feeding skill But so much of my sessions are spent talking with the parents finding out what their struggles are day to day mealtime to what their goals are for their kid because sometimes the goal that I have for the patient is It's very different from what the parent has for the patient or for their child.
[00:54:35] Praveen Goday: That is really true. And sometimes they are achievable. Lots of times they're achievable, but sometimes they're not. 
[00:54:42] Madi Metcalf: And so always just like talking with the parents and forming that good relationship and rapport to make sure that you are, you know, coming up with reasonable goals that are, you know, aligned with the parent, with the family's culture and values.
[00:54:57] Praveen Goday: Correct. Yes. Absolutely. 
[00:54:59] Madi Metcalf: Do you have any tips for diet expansion or volume expansion that you have given parents before? 
[00:55:11] Praveen Goday: Wow. No it's, well, it all depends on the child, right? So when children are older, I talk to them about trying to expand their diet, but these are the less picky eaters and possibly.
[00:55:24] Possibly better. The, the thing about low volumes is that apart from using appetite stimulation, the only thing we can do is pack more calories into a small volume. So that's where the high calorie beverages come in and there's no getting away from them. Yeah. It's, it's much harder to expand diet though.
[00:55:50] There is something called shaping, right? Like you go from A to changing A slightly so that it becomes closer to B and then ultimately you end up with B. So shaping is something that you can do, but it's hard for parents to do at 
[00:56:07] Madi Metcalf: Yeah. And even working I don't know. Sometimes I can come up with the most fabulous food chain that I'm like, Oh man, this is beautiful.
[00:56:15] And then I take it in and the kid's like, nope. 
[00:56:19] Praveen Goday: And the other thing is I think, I think therapy sessions are not real life sometimes, right? Like what we can do in therapy then doesn't translate to home because there are three other kids and, and life happens and it can be tough. 
[00:56:34] So one hopes that it works, but one never knows if it's going to or not.
[00:56:39] Madi Metcalf: I recently switched from a clinic where I saw all of my patients in clinic to providing home based services. And it was so eye opening to me because, you know, we would have amazing sessions in the clinic and the parents like, Oh yeah, we did this, but you know, we're just not seeing a whole lot of care over at home.
[00:56:58] And then I get into the home and I'm like, Oh, this is very different than our very quiet, controlled, unstimulating clinic room that we've been working in. And it's been a little shocking to me how much I've changed the recommendations that I'm making and the way that I'm even approaching therapy just because it's completely different than what we see in the clinic.
[00:57:24] And so it made me realize how much I thought I was listening to parents, but there's so much more listening I could be doing to better understand what they're actually going through at home. 
[00:57:36] Praveen Goday: So in our intensive program, we are trying to incorporate a few video sessions at home towards the end of the program so that we understand what we are sending the child back to.
[00:57:46] Because here we are, we have the kid kind of, you know, imprisoned in our program and all they have to do is feed the child. Once they go home, that's immediately going to change, you know, the other children the family, the whole nine yards comes back into the picture. 
[00:58:03] Madi Metcalf: Do you do those video recordings before they come in or after they've been in the program for a time?
[00:58:08] Praveen Goday: Oh, it's not a video recording. It's actually providing therapy over video for some 
[00:58:15] Madi Metcalf: Oh, oh, oh! 
[00:58:16] Praveen Goday: Them. Yes. So, yeah, we're trying to do this once or twice during the eight weeks so that we understand what's going on at home and we're sure that parents can replicate whatever we are teaching them at home. 
[00:58:30] Madi Metcalf: Was that in place before COVID or was that implemented after COVID?
[00:58:33] And we kind of learned about, 
[00:58:34] Praveen Goday: Well, 
[00:58:35] Madi Metcalf: we, 
[00:58:35] Praveen Goday: we, we didn't really have zoom before that. So I was not part of this program then, but I don't, even now we're still having, we're still trying to figure out exactly how we're going to do it. And we don't do it consistently, but we're trying to get there. 
[00:58:52] Madi Metcalf: Okay. I think that's an awesome goal for your program to work towards.
[00:58:56] Cause it. I don't know. It just is so different seeing that home environment versus what we can create in the clinic. So I think that's an awesome Move that you guys are making. 
[00:59:06] Praveen Goday: We we want children to be doing well at home. 
[00:59:10] Madi Metcalf: Right. 
[00:59:10] Praveen Goday: doing well in therapy is all fine and dandy, but we, we really need them to do well.
[00:59:15] Madi Metcalf: Yeah. I always tell my, my, my families that I work with, I say, they're like, Oh man, he does so great with you. And I'm like, that is amazing. I'm so happy that your child eats for me, but I really don't care about that. I really care that he eats well for you. I'm not the one that's feeding him all the time.
[00:59:31] You are. 
[00:59:32] Praveen Goday: Yeah, exactly. That's absolutely true. 
[00:59:35] Madi Metcalf: Well, Dr. Goday. I learned so much from you tonight. I'm just so excited to take some of this information that I've learned tonight back into my practice. I've learned a new tip to use for my kiddos who are taking superheptadine that I'm excited to implement.
[00:59:50] So thank you so much for that. And thank you so much for all of the amazing work you're doing for building more awareness and more. Solidarity on what we are calling PFD and how we are treating it. It's really important work and I'm glad that it is being done. So, I have put in the link for a couple of articles into the chat if you guys are interested in grabbing those before the episode closes or the webinar closes out.
[01:00:23] Thank you so much again for attending another episode of Making Sense of Selective Eating. I look forward to seeing you on our next one. And thank you again, Dr. Goday, for sharing your expertise on pediatric feeding disorders. 
[01:00:37] Praveen Goday: Thank you, everybody, and have a good night. 
[01:00:39] Madi Metcalf: You too, Dr. Goday. 
[01:00:41] Praveen Goday: Thank you. Take care.
[01:00:42] Bye.
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