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Beyond the Numbers: Navigating Outcomes for Therapeutic Success with Dr. Katherine Sanchez

 

Brianna Miluk: Hello, hello, and welcome to The Feeding Pod. This is your host, I'm Bri, Brianna Miluk, and I am a speech language pathologist and certified lactation counselor. I specialize in infant and medically complex feeding and primarily see patients in the home health setting, although I do have some that I see an outpatient or via telepractice.

I'm also an instructor at the university level and a PhD student studying communication and information sciences. I have a huge passion for evidence-based practice and supporting information literacy in speech, language, hearing, feeding, swallowing sciences, specifically as it pertains to social media and translational research.

This podcast is meant to share anything and everything related to being a pediatric feeding SLP feeding therapist with sprinkling in a little bit about working in academia, being a Ph. D. student, and how to access, appraise, and implement research into clinical practice. Some episodes may contain guests, and I'm already looking forward to some of those coming up, while others might just be me rambling about something that's been on my mind.

Regardless, my goal with this podcast is that you walk away not just with newfound knowledge, but with the inspiration to think critically and not be afraid of research. So, without further ado, let's get into today's episode.

Welcome back to the feeding pod, this is Bri, and I'm so excited to have Dr. Katherine Sanchez back today. I just adore her so much. And if you don't already know by now, she is one of the mentors in the advanced pediatric feeding mentorship group. And that's because she just brings so much clinical and research experience in.

And I think that's really important for, for everybody that's part of the group. But I also value that so much as, as Katherine being a friend of mine. So, I'm so happy you're back. I keep bringing you back. I keep, I keep being like, we've got more, we've got more to say, we've got more to talk about. So. 

Dr. Katherine Sanchez: You know, Australian boomerang, there's that whole analogy.

Brianna Miluk: Yeah, there it is, that's what it is. 

Dr. Katherine Sanchez: It comes back to you. 

Brianna Miluk: It's going to come back around every single time. And I feel like always the discussions we have are just- they're very nuanced, which I think is fun to talk about in this field. So, Katherine, why don't you kind of give everybody just a quick reintroduction if, if they have, or I guess, new introduction, if they haven't listened to one of your episodes before, but just kind of give a brief overview of, you know, some of your experiences and then what you're kind of into now.

Dr. Katherine Sanchez: Yeah, absolutely. So, I am, I live in Melbourne, Australia. So, if you're hearing the accent, that's why I have my own private practice, Protea Therapy where pretty much all of my clients now have sort of complex pediatric feeding disorders including dysphagia. And I also provide sort of mentorship and supervision to clinicians in those spaces as well as an implementing EBP in the pediatric feeding space. I did my PhD finished that four years ago. I calculated by the age of my youngest child who was born just when I finished. 

Brianna Miluk: I love that. 

Dr. Katherine Sanchez: And that was in communication and feeding outcomes in children born before 30 weeks of gestational age. So that was an opportunity for me to really dive into the literature around kids with medical complexity and, and their sort of outcomes once they get out into the community.

And I think really sparked my interest in that area. As well as working in private practice. Obviously as you said, I'm a mentor in the Advanced Pediatric Feeding Mentorship group. And I'm also the special topics editor for the pediatric medical topics at The Informed SLP where we sort of translate research into clinically actionable information.

Brianna Miluk: Yes, I love that. And I, I even like had a note written down to like re-bring up The Informed SLP because a lot of the stuff we're talking about I think can be, The Informed SLP really helps you problem solve through a lot of this and in taking that information. So. What we're going to talk about today is really going through understanding outcome measurements in research, talking about what outcome measurements researchers use, why maybe they choose the outcome measurements they do, and then how those outcome measurements are applicable or valuable or even matter to clinicians, you know, and what type of outcome measures really make a difference for our patient and client care.

And so. Before we kind of, like, get into, like, the fun, the fun part, let's just talk about, like, outcome measurements in general, okay? So, Katherine, give us just, like, what, what do we mean by outcome measurements and what maybe types of outcome measurements would people be more familiar with?

Dr. Katherine Sanchez: Yeah, absolutely. So, outcome measurements they do what they say on the tin, right? We're looking at the outcomes usually of a therapeutic intervention. And we're measuring that in some sort of formal way. So, there can be lots of different types of outcome measurement. You might use- You know, you might use something quite formal and standardized but there are lots of other ways to measure outcomes as well.

In the feeding space, we have a lot of PROMs patient reported outcome measures, although they tend to be propped by proxy. So, caregiver questionnaires that are standardized and that can help us sort of measure outcomes over time. But there are also tools like goal attainment scaling or "GAS" and other types of sort of outcome measurements.

AusTOMS is one that we have in Australia that you can use to sort of focus more holistically on the person or the child. And I guess the importance of that is firstly we wanna know that what we're doing is working or that it's not working because then we need to change things up. So, it's really important to have a bit of a metric around- 

Brianna Miluk: The dog, just walked through the door, just let herself in.

Dr. Katherine Sanchez: Yeah. No, I love it. It's like that video with the kid in the bouncer and the news guy in the- 

Brianna Miluk: Oh, yes. Yes.

Dr. Katherine Sanchez: Um, so yeah, we want to know whether what we're doing is working or not working so that we can change our plans accordingly. But also, outcome measurements can be really important for funding for proving yourself to to insurance or or other funding bodies to provide evidence that it's worthwhile them continuing to pay you.

So, they have really practical uses and then of course they're very useful and necessary in the research space as well, because when we're testing a new intervention, we need to know whether it does anything or not. 

Brianna Miluk: Yeah. And I think that's where outcome measurements, you know, we think about it a lot more in like the research space. I think when we hear that term a lot of the time, it's like, okay, what they were managing, you know, what was the effect of this type of intervention? Like what was the outcome from it? But we use outcome measurements. constantly in clinical practice as well. And so, this is one that really carries over. And one of the things that, you know, stuck out, stood out to me that you said is sort of, how do we determine.

I'm trying to think of, I'm trying to remember exactly how you said it, but basically thinking about like, we're considering like the success of therapy. Right. So, thinking about like this outcome measurement means that we are successful and progressing toward a functional outcome. And how do we really determine which outcome measurement is what direction we should be going in? And that where it goes into like. Looking at some of those more like holistic versions or even like value-based outcomes, I think can be really valuable. I'd love to hear you talk on that. 

Dr. Katherine Sanchez: Yeah, absolutely. And I think I think it's really interesting to look at this space and look at what outcome measurements we're choosing and why. Because if you're choosing it for sort of that practical, I want to prove myself to insurer reason, then you're probably going to choose like a standardized tool that gives you a numeric outcome that is really sort of obvious to demonstrate in your documentation. But if it's more for the purpose of, of sort of measuring whether what you're doing is working and working from his perspective, right?

Like, and who are you trying to show it to? Are you trying to show it to yourself? Are you trying to show it to your supervisor? Are you trying to show it to the parent? Then it becomes really important to be selective about what you're choosing. You don't want to just go in and say, all right, well, I'm going to use the PediEAT as an outcome measurement for every child.

Because maybe that's not, it doesn't align properly with the goals that you're working on. And so, I think, you know, there's a whole range of different outcome measurement tools in the space, in the pediatric feeding space that we can we can draw on to be really specific about, about what we're doing. And and I know you and I both really like the Infant Feeding Care range of tools that used to be called the Feeding Flock tools. 

Brianna Miluk: Yup! 

Dr. Katherine Sanchez: But, you know, I think they're, they're a really good example because you've got ones that are like about mealtime family functioning, and then you've got ones that are about oral motor skills.

And the one that you, you know, the one that you select for your outcome measurement is gonna be different depending on what you have been working on with that child and what the goals of the family are. Do they really want the child to be able to chew more efficiently or do they really want the child to be able to participate in family celebrations?

And that, yeah, I think that's good. It's really important to be considering that. There's a great recent systematic review as well that Dr. Jane Marshall has just published looking at PROMs patient reported outcome measurements in the specifically focusing on the feeding skill domain from, of pediatric feeding disorder. So yeah, there's some nice ones in there to look at. 

Brianna Miluk: Yeah I think it's really interesting too, with the PROMs and thinking about like how I've, and I do not remember who wrote this article or like, I literally, I would have to like do my little search in my Zotero. But there was one that talked about how there's like a disconnect or there tends to be like, significantly different ratings if you use like a very similar outcome measurements and had like a caregiver rate how feeding's going versus the feeding therapist rate how feeding's going and like looking at the different skills alongside it and how there's this mismatch and so I think that also goes into where when we're using tools like that to support, like navigating what direction we might go in with therapy or where we find the strengths and the weaknesses.

That's where we also can't only rely on the tool to serve, like, what is going to be the most functional outcome for this child and family, because there could be a total discrepancy in what we think should be a priority and what actually matters to them. 

Dr. Katherine Sanchez: Absolutely. And I think, you know, what you're speaking to is that capacity versus performance dichotomy, right? Like if anyone hasn't read our amazing piece on motor feeding that you and I and Kristen put together. We'd spoken about a little bit there that that you have to think about whether you want to focus on capacity, which is what can a child do in a highly controlled supported environment, like in a clinic room where they have the perfect seating and no distractions and and, you know, the parents have made sure to bring them in hungry and rested and versus what can they do from a performance perspective in the real world where things are messy and, you know, and literally and figuratively and it's not always the perfect circumstances because their, their lives are not capacity, their lives are performance. So, we need to be thinking about that with outcome measurements. And that's why I think PROMs can be so useful in the feeding space, because we don't really, you know, it, it is interesting to know what they can do in the clinic. But what makes a difference to their lives is what they're doing day to day at home, at childcare, in all of the other places where they function through the day.

Brianna Miluk: Yeah, and I think it reflects on even like PROMs can reflect on even more than what the child's skill is, but also like how the caregivers feel about what's happening. And I think, you know, we've had conversations about this and I've talked with others as well. I think I've probably mentioned it on the podcast too of like that psychosocial piece is often so quickly overlooked when in reality, like that could play an even larger role in the skills developing or that like discrepancy piece of like, how do they view what's going on versus what is actually going on. And I think that's where PROMs can play a role in that as well, because it's- you are getting that caregiver report or, or patient report, depending on, you know, if they can report it. I know most of the kids we work with are, are littles or may have trouble communicating that. So, paying attention to, you know, how do they feel about it? And I think that also goes just into our interventions as well.

Like when we make a recommendation, just how do you feel about that recommendation? Do you feel that that's something would work for your family? We actually, this kind of makes me think about what we were talking about in Slack earlier this week when you had mentioned how you will phrase your questions and ask questions to help guide caregivers in really determining like what is best for them and their family versus you giving like a direct, you know, instruction to them on, on how to make things better.

Dr. Katherine Sanchez: Absolutely. And I actually think this is this laid so nicely into thinking about whether goal attainment scaling is like a useful tool for you and your clinic, because that's a really great tool for having those discussions with families as well. And really aligning your expectations. So. For people who haven't come across it before goal attainment scaling or GAS is basically where you sit down when you are setting goals with a family and you say, okay, so our goal is we want to expand their texture variety, and then we want to expand the number of- the types of textures that they are accepting.

So. What would it look like if we made absolutely no progress on on this goal? And then we write that down and we score that as zero. And then we say, okay, and then what would it look like if we made amazing progress on this goal and just met it to, to, you know, to every expectation and dream that you have for therapy.

And then we write that and usually that's like a two. And then we're like, okay, so what does it look like if we're like in between no progress and a two, what would a one look like for us? And then we write that down and we define it really closely. And then we go and say like, well, what about if things get worse?

Like, what if something, what if this child seizures increase? Or, you know, or they go on a new medication or, you know, they, they're just tired and sick and and things go backwards. Let's, let's put in a negative one there and you just build up this, this scale of of what would the outcomes actually look like to you?

What, what are the outcomes that are important to you? How can we define those and really operationalize those really closely? And then you, you end up with an outcome measurement that's completely tailored to that family. And you get to have those really nuanced, deep conversations about their expectations of therapy and you put a timeline on it as well. So, you like, you know- 

Brianna Miluk: Yes! 

Dr. Katherine Sanchez: What are your wildest expectations that we could achieve in a three-month period of, you know, of seeing you weekly? So yeah, I think that that can be a really amazing tool to, to be very tailored and individualized to the clients. 

Brianna Miluk: I love that. And I feel like it's something that you could use. So, for example, in the States, if someone is in early intervention, the goals are quite literally written by the families. Like you ask the family, what do you want your child to do? And they write that in there. Many States don't even worry about if it's super measurable or not. They just kind of like, I want them to eat more foods, you know, and they just like throw that in there. However, I think this is something that could be used in that type of setting, right. To help, help caregivers navigate that, to come up with goals that are, you know in line with, with how they feel with what's going on and what's causing them the most concern.

But then also clinically I'm thinking about, you know, if I was to write a goal, like. Child will eat more foods. Insurance would be like, what does that mean? Like, how are you measuring that? You know, where are you going through that? And so, I think using that to help understand like what the caregiver's priorities are, but then us using our clinical experience to say, okay, here's how we can make this measurable so that we can still, you know, submit to insurance while still focusing on what the caregiver cares about and still, you know, going into that direction.

Like, we can provide the nuance to make sure that we show the medical necessity of it. But we can still make sure like our functional outcome that we're working toward achieving is based on what they need and and what's best for them. 

Dr. Katherine Sanchez: Yeah. 

Brianna Miluk: That's cool. Very cool. I will make sure to link that in the show notes for everybody to look into.

Dr. Katherine Sanchez: Fantastic. I think it's such a good tool and it's so widely used in OT and physio, physical therapy. But I'm not sure that we use it as widely in speech pathology outside of those really like transdisciplinary programs. So, I think it's like an untapped resource for us that I- 

Brianna Miluk: Yeah. 

Dr. Katherine Sanchez: It would be really interesting to see it being used more.

Brianna Miluk: Absolutely. I think that would really help, help better align our therapy goals with family goals and what they, what they want to see, see in outcomes. So, let's move into talking about how aligning these goals- so aligning our outcome measurements for therapy, really how they can affect the patient, the family and the healthcare provider.

Cause I think it can affect like the whole, everybody in more than one way. Now we've, we've kind of touched on the fact that like, okay, it makes sure that the care we're providing is more family centered and is more patient centered or patient driven, but like, why does that matter? Right. And so how does that really affect therapy as a whole?

Dr. Katherine Sanchez: Yeah. And I think probably a huge part of this is, is buy in. Right. Like making sure that families, if you, if you have a family that feels like they're being listened to and that they have come in with these goals and you're like, okay, well, here's how I'm planning on meeting these goals. And here's how I'm going to measure whether we're actually meeting these goals at these time periods.

If a family has that really clear direction and they can link what you're doing in therapy and what the home practice is with that direction, they're much more likely to be completing the home practice because they can say that it's purposeful. It's not just, you know, some random activity that you've swept in and told them that they have to do for their child's development.

Because you've linked it all in, you've said, you know, okay, well, your goal is that you want your child to be able to come to the table at your Christmas dinner and, you know, and and maybe have something on their plate and, you know, and be part of that Christmas meal. Okay, so let's- let's- what skills do we need to get there?

And how can we meet each skill? And how does our home practice help you meet that skill that eventually works towards that, that Christmas dinner outcome? So, I think, you know, the family's going in feeling heard and feeling purposeful and feeling like you're all part of the team together. It's not the child has a team that's composed of professionals.

It's the child has a team that includes the child and the parent and everyone is on the same page and everyone's working towards the same goal. I think that's so critical and I have definitely encountered parents who have come to me. And, and fed back that you know, they, they might have been in a program where they didn't feel like they had a clear direction where they were, you know, coming in and maybe they were doing food play or, you know, or maybe they were doing you know, eating every, every week when they came in, but they didn't know what they were working towards and they didn't know whether anything was improving and it's really hard to feel committed when that's the case, when you don't know where things are moving to or where they should be moving to or whether they're getting there. I think it gives us some accountability as healthcare providers as well to think, okay, well, we said by, you know, by X date that we were going to be aiming for this and, you know, and so this is what we need to sort of get through if we're going to meet that goal.

And of course, you're not always going to meet the goal that you've set, you know, things get in the way life gets in the way kids can change, situations can change. But but if you have that in the back of your mind, then I think that's really helpful for us as well, not to just get caught in. I'm just doing the same thing every week.

You know, I'm getting out my favorite game cause the kid likes it. And and we're, you know, having a muck around and having a good time. You don't get caught in that- 

Brianna Miluk: Yeah like complacent with just doing the same thing over and over and yeah, not recognizing that he's not changing. 

Dr. Katherine Sanchez: Yeah, that's right. That's right.

Brianna Miluk: I think the sort of one of the first points you made where you were talking about, like sitting with the family and saying like, okay, so like, this is your goal, here's what I'm thinking about to, to as steps to get us there as strategies to get us there. And we're always going to be doing all of these things to work toward there.

And I truly think that that's something that I need to improve on because a lot of times I'm like, you know, like. Here's goals. Do those align? Do you feel good about these? Like, you know, based on what you say, it seems like you want to work on and like creating goals with the caregiver. But I feel like that's an area I need to improve on is like going, revisiting them and saying, Hey, you know, how we started doing X, Y, Z, or, you know, we did that.

That's working towards this goal that we set up together and like revisiting that over and over. I find myself like doing it when I like, you know, have to, cause it's like progress note time, let's talk about it. But it's something that I really need to integrate more. So, I'm glad you brought that up. I'm glad we're having this discussion because it's, it's helping me reflect too, to, to say like, okay, that's something that I could do better is make the connections more frequently.

And I think sometimes there's the barrier of like you're in a session so you feel like you have to do like just therapeutic stuff, you know, and like you don't consider the fact that counseling the caregiver all the time is totally therapeutic in that nature. And if we're not counseling on a feeding strategy that doesn't mean it doesn't matter.

It doesn't mean it's not helping with the long-term outcome and so I think kind of changing my mindset with that of like spending a little bit of time doing that, it's helpful. And actually this, this past week sat down with a caregiver in a session and we went over the child's IEP. So that's like the, the goals that the school system sets up.

And we said, okay, based on the progress we made this summer, are these still okay? Do we need to change them? Let's go through them. What questions do you have? What concerns do you have? And we worked through it and it's like. That's totally, you know, therapeutic because we're counseling on the progress that's been made, making sure that moving forward that the outcome measurements do make sense and the child's going to get the support that they need, but not too much support because they've made progress and kind of navigating that. So, I appreciate it.

Dr. Katherine Sanchez: Yeah I think that's so important and I think that probably I spend more time on the sort of counseling side of things than I do on doing the thing, you know, like I'm, I'm not spending, you know, the majority of my session feeding the kid in most cases, in most cases, I'm spending most of the time talking to the parents- 

Brianna Miluk: If I am feeding, a lot of times I'm talking to the parent at the same time, you know, it's like, okay, now it's your turn. All right, you, you come in. 

Dr. Katherine Sanchez: Yeah, exactly. And it's really, it's it's been interesting. This is a bit of a digression into like note writing. But I often talk to people about note writing and my notes. And very often. So, when I, when I structure my soap notes in my "O" section, I do it as like goal one, what's the goal?

And then a few dot points, goal two, what's the goal? And then a few dot points, I almost always have a goal around, like, I might have a goal around case management which is, you know, we're talking about funding or we're talking about you know what are the professionals we might loop into?

And I'll usually have at least a few dot points that are about the informational counseling that I have done. And when I talk to when I do supervision and those sorts of things, I find that a lot of people are putting that in the S section of their soap notes, like the subjective section, like they think of it as something that the parent is just reporting to them.

Like it's not intervention. Like it's not something that they're sort of giving to the parents as part of their service. And I think that's really worth reframing because I think that that that informational counseling is, is a really critical part of our intervention. It's not just our rapport like. 

Brianna Miluk: I love that because we know counseling is within our scope, like counseling on the things within our scope, right? Like if a caregiver additional support outside of what I can provide them, then yes, I need to see, but counseling on the very things we're doing. And the reasons we're doing them, that totally makes like, how is that? I'm having a moment. That makes so much sense. So, I always prioritize writing a caregiver goal because I like the, the accountability it has on them of like, we're writing a goal that also like encourages your involvement and participation and carry over.

But I never thought about writing a goal. To like hit certain points that we've counseled through that we've worked. I love that. I love that. That's so- yeah, because I totally put it in the subjective. I totally like any any counseling that I do, it's either in the subjective or it's in like my plan of care for like next step, my recommendations moving forward is like, and then we talked about blah, blah, blah, blah, blah, blah, blah, blah. And it's like, no, that told I like this. I like this. 

Dr. Katherine Sanchez: Yeah, I. I just, yeah, and I can't even, I don't remember when I started doing it that way because, you know, I had a bit of a sort of break from conventional clinical practice. When I was doing my PhD, where I was mostly like, I was doing some groups and some outpatient clinics and stuff, but but not having sort of sustained ongoing therapeutic work with kids. And so, yeah, so when I started my private practice, like this was just the way I started doing it and it made sense to me. And then when I was doing supervision and people were like, oh, this is my note. And I was like, but like three quarters of your S is actually intervention, like is actually stuff that you are doing to support the family.

You need to pull that into your O, like that's. Yeah, it was just really because it hadn't occurred to me that that would be a misalignment. And what the implications of that were, but I think that it links really well into these outcome measures, because if you have outcome measurements like around functional outcomes or, you know, family goals, then a lot of the stuff that you do towards those functional goals is going to be informational counseling based.

Brianna Miluk: I mean, it makes a lot of sense. And I think, I mean, this is me just like. Literally having an epiphany moment, but so now my brain's like going in a hundred directions, but I- 

Dr. Katherine Sanchez: We'll just make a podcast episode break. 

Brianna Miluk: Yeah. Right? I'm curious though, if part of the reason so many of us think of those as being subjective is because so many speech and language goals are written in very, like, objective terms, that's what you target in those strategies, and there's less of the counseling as with feeding. I feel like in pediatric feeding, so much of what I do is counseling and supporting the caregiver in, okay, to, you know, to apply something.

And so, I wonder if that's sort of where like, so many of the teaching and trainings are around that. Whereas like you mentioned in like even talking about the, the GAS and like OT is with- Oh, sorry, hold on. I got a snooze. That's my cat's insulin alarm. I got to go check him in a second. But I wonder if that's why like where OT focuses very heavily on like activities of daily living.

And so, in those situations like that type of counseling and supporting through stuff like I'm curious if if they use that even more than speech language pathologists do and if part of that's because of the nature of like the majority of the field. 

Dr. Katherine Sanchez: Yeah, that's interesting. It would be interesting to see whether there's a difference in how like clinicians that work on like early, early language, like, you know like Hanen-y type of- 

Brianna Miluk: It's very caregiver heavy.

Dr. Katherine Sanchez: Exactly. Very informational counseling, whether they would document any differently to the way that people who are, say, working on, you know, speech sounds. 

Brianna Miluk: Well and I'm even thinking, like setting wise, like speech sounds in the schools is going to be very different. Like you have very limited caregiver contact, if at all, as compared. So. That is interesting. And I'm also going to start writing all those goals and I'm supervising grad clinicians this semester and I can't wait to tell them to write those goals. Like I'm, I'm so excited about this because I, what an important outcome measurement that I've been missing for so long. Like, you know, I'm doing it. 

Dr. Katherine Sanchez: Yeah of course. 

Brianna Miluk: But I haven't been measuring the fact that like this is a very important part. 

Dr. Katherine Sanchez: It's the core of what we're doing because it's all performance. 

Brianna Miluk: Yep. Yep. And that's why I think my notes sometimes seem so heavy in the subjective, and it doesn't seem as heavy in like the data points of the objective piece because of the fact that that's You know, it's, it's dialogue that's happening most of the time. So that really interesting. 

Dr. Katherine Sanchez: And I mean, my feeding notes do end up being quite subjective heavy as well, but I as I go through my, my, my check is if I have said anything to the family, it goes in the O section. If the family says it to me, it can stay in S, but anything that I'm saying, any new information that I'm bringing in that needs to go in O because that's- that's yeah, that's an intervention. I'm afraid. 

Brianna Miluk: I love that. I love that. I think like I said, a lot of the times I was kind of putting it into that like plan of care, recommendation, like next step sort of thing. But I think putting that in the O with just like my immediate takeaway is like kind of just reformatting that and, and also just like having a goal that talks about those specific things that we need to counsel through to show the progress toward the caregiver.

Cause like all of those counseling things are leading toward the caregiver feeling more competent. in what they're doing and feeling decreased, you know, stress and anxiety around those meal times. So yeah, I love that. I love that. Okay. So, another thing that I want to talk about is kind of just some examples of this.

And I know we had talked about two specifically if we're thinking about like outcome measurements that typically happen and things in different, different types of feeding therapy approaches, but also things that we see in the research as outcome measurements too. So, you know, how, when we're looking at a research article that says, and, and I'll, I'll talk about our first example here.

So, the first example we were going to talk about is sort of like ABA or behavior-based feeding therapy and the outcome measurements that they use in those types of interventions. So, when you have a child who goes to a clinic that implements these types of interventions, but also the research also tends to, you know, show some of the, the same types of outcome measurements. So, can you give an example of both and kind of why this may or may not be good, you know, clinically what we're looking at? 

Dr. Katherine Sanchez: Yeah, absolutely. So I think and this is what really got us thinking about this topic, right, is looking at outcome measurement in the research and how that can impact on the way that you interpret and apply the research, because you can get this whole body of, of sort of literature that that's like, this is the best feeding therapy approach.

But in your process of reading the papers and critiquing the evidence you might get to You should examine the outcome measures because they can sometimes not align with the outcome measurements that you might be thinking about for the goals that your clients have. So, for example, one thing that we can see in a lot of papers is that a major outcome measure is bites accepted.

So, if I, if I offer you this bite on the spoon, do you physically take it with your mouth? And how many bites are accepted? And maybe it goes up from zero bites accepted on average at the start of the intervention to, you know, 30 bites accepted on average at the end of the intervention. And then they're like, look, our therapy works because it's increased the number of bites accepted.

If you drill down into that and think, okay, who is my client and what do I want for them? What do their parents want for them? What is going to be helpful to them in their lives? Is it bites accepted? 

Brianna Miluk: Like I also think this is a total like side note, but the whole bites accepted or bites tolerated makes me grrr. Because like, what does that mean? What does acceptance mean? Like, we accepted it because it was the only option we had in order to discontinue a mealtime? It was the only option we had to not be ignored? Or, you know, and, and, yeah, that's a side note. But I think that goes into what you're saying of like, does this align at all with what the family really wants?

Dr. Katherine Sanchez: Yeah, and I don't think it is a side note. I think it is a... Middle note- a center note. 

Brianna Miluk: An interjection maybe that's what it was- relevant, but I just had to interrupt you because I was feeling it. 

Dr. Katherine Sanchez: Yeah, no, totally. And like, and we, we should be looking at these outcome measurements in in the research that we're looking at to see what, what interventions we should be offering. And we should be thinking, are these outcome measurements value aligned for our families?

Do they, are they going to work towards what our families are looking for? Or are they, is bites accepted going to contribute to my child can sit with us at Christmas dinner? Are they going to contribute to my child can safely attend daycare? You know with, with the meals that are served there?

I don't know, maybe, maybe not, but I think in a lot of cases, we're extrapolating this research in a really sort of gross, big, un nuanced way. I don't mean disgusting, but you know- 

Brianna Miluk: That too sometimes. 

Dr. Katherine Sanchez: Sometimes. But you know, we look at this research and we're like, oh, okay, well they had a change from point A to point B, and so this therapy is effective and so I should use this therapy with my clients. But in actual fact, we need to think more about the outcome measures that are used in research because it's not always applicable to our clients for lots of different reasons. 

Brianna Miluk: Yeah. And I think too, sometimes when we, when we see some of these like research pieces, I'm thinking specifically about when we see these like behavior-based approaches where there's an outcome of like, you know, bites have increased what these programs are doing are not very sustainable for a caregiver to do in the home and carry on.

You know, from clinical experience, I had a kid one time who went through an intensive behavior program and when they came to see me, I'm like, because one of the first things I do in an eval is like just show me what a meal time looks like. Like I'm going to be totally hands off, just set it up, do whatever interactions you do.

Like, let me see what it looks like. And I remember mom bringing out a tray that had three bowls of puree. Each bowl had a different spoon in it. And she had a timer and she said the meal time is scoop, hold it in front and take a bite. She hit the timer. You have 10 seconds to swallow. Otherwise she was going to ignore him.

And if you, if you did swallow, then you got like a toy for a minute and then, or for like 10 seconds. And then it was the next bowl. And then the next bowl. And it was like, That was a meal. And it's like, okay, we do have more bites accepted, but none of this is leading toward functional, independent eating, increased enjoyment around mealtimes, the caregiver feeling less stressed, if anything, they're more stressed because they're trying to keep up with all the different things. And it just, you know, so on paper. It looked like what was being done was working and you know. 

Dr. Katherine Sanchez: Yeah. Well, and it was, it, it was working. It was working at making the child accept more bites in that- 

Brianna Miluk: For what it said. 

Dr. Katherine Sanchez: But do- is that what you want out of therapy? Like is that what you're looking for? Yeah.

Brianna Miluk: Mm-hmm. Mm-hmm. Yeah. And that, yeah. 

Dr. Katherine Sanchez: It just should work or effective, that is all tied up into what? The metric, what the outcome measurement that is being used is, and that's what's so critical to look at it in the research. And and I, we talked about this a little bit in NICU as well, where a lot of the metrics, for political reasons, the success metric main success metric is often length of stay. And that is a very important success metric for hospitals because the shorter the length of stay, the cheaper it is for them. And so, it's really, it's no shade on researchers for using length of stay as a metric, because that is what is going to get things implemented into hospitals from top levels, because they're going to go, look, this is going to save us money. So, let's start implementing this, but when we're looking at- 

Brianna Miluk: Also, earlier from what you said about like funding the research too, length of stay is a measurement that's going to get funding. 

Dr. Katherine Sanchez: Exactly. Yep. It's going to appeal to the doctors who are looking at research grants and going, Ooh, it decreases length of stay. Excellent. Always like an old white man voice.

Brianna Miluk: Yeah. 

Dr. Katherine Sanchez: But but yeah, when we're looking at an individual infant in front of us, are we thinking about whether this whether the feeding intervention that we're delivering is going to decrease length of stay, or are we thinking about whether it's going to create a, you know, a bonding mealtime opportunity between the parent and the child or whether it's going to result in them being more efficient so that they can, you know, happily take more of their volume orally before falling asleep. Or, you know, you might have lots of, lots of goals depending on what, you know, you're talking about with the family, the child looks like, but probably relatively few of them. It's going to be a secondary goal for you more likely. 

Brianna Miluk: I think too and I had written this one down after we had talked about the NICU, one that I have also seen pretty frequently is like time it takes to wean from a tube feed and the amount of time, you know, from this type of intervention versus this one to get a child 100% off of a tube.

And. What I find is, again, we have to reflect on like, okay, the outcome measurement was time off the tube. The outcome measurement was not child is independently self-feeding or is demonstrating enjoyment around mealtimes or that the child is an active participant or that they're eating a variety, you know, none of those mattered.

What mattered was like just getting them off the tube. And so again, reflecting on that a little bit, because if the goal is to get them off the tube, then it's like, well, maybe we just want them to drink one formula, you know, so we can say they are getting the calories orally and that's all that matters. And then, you know, and that's, that's fine.

If that's what the caregivers want, that's what they want to work toward and, you know, helping them recognize like. If we go with this type of approach and down this, you know, avenue, and that's the ultimate goal right now, then if you also are wanting to build skill or variety or, you know, increase independence or self-feeding, those might have to be on hold for a little bit.

If we're putting all of our attention there, or if we're not worried about it being the least amount of days possible, then we can navigate, you know, both of them together. And so that's kind of where it goes into like, Some of what the research says about tube weaning approaches, but also aligning that with, again, that caregivers outcome measurements. So, taking the two together. 

Dr. Katherine Sanchez: Yes. Yeah, absolutely. It just feels like something that that we're not often taught to critique in research papers, right? Like, you know, that you look at the methods and-

Brianna Miluk: Look at the results and go. 

Dr. Katherine Sanchez: Hey, and like. Is the, you know, what's the sampling like and and how big was the sample and what sorts of kids did it have in it? And then we're like, okay, yep. No, it can critique all of that. It was a small study that only looked at, you know, one particular group of children. And then we just completely ignored the measurement part of it, even though that has really real and important clinical implications for us when we're interpreting that data into our caseload.

Brianna Miluk: Yeah. Yeah, absolutely. No, I think those are both, both great points and kind of leads us into I have some rapid-fire questions for you. So, I do not prepare anyone for these. I just kind of come up with two or three that I think would be fun for you to answer. So, one that I do tend to ask a lot of people, but I think it's really interesting to hear. And it also selfishly adds to my list, but what is either like your current favorite book or your favorite children's book? You can answer, answer either one of those. 

Dr. Katherine Sanchez: Oh, man. So, I've just come back from a two-week holiday and a three-week holiday and I got to do lots of reading, which was so amazing. And probably I, when I was away, I think my favorite book that I read then, like choosing a favorite book is like choosing a favorite child. 

Brianna Miluk: I know that's unlike your current favorite book. 

Dr. Katherine Sanchez: I like that. But, but when I was away, I think my top pick was a book called [The] Priory of the Orange Tree. I am a big fantasy reader. I love fantasy. 

Brianna Miluk: I did know that about you. 

Dr. Katherine Sanchez: Yeah. And this is like a doorstop, like it's a big book and it's got a prequel and the prequel is maybe even better. Like they're, they're both just really good. But it's, it's pitched by the author as like a feminist retelling of St. George and the Dragon.

But it's so much more complex than that. And and what I am loving about like reading contemporary fantasy now as well is that it's so much more representative than it used to be. So, it's this amazing, rich fantasy world that includes. You know that has lots of women doing all sorts of different roles, not just being, you know like the Arwen, Eowyn Lord of the Rings archetypes.

And incorporating banners when everyone's doing important stuff. So, it's got women in powerful roles, but it also includes lots of people of color trans people, non-binary people as, as part of sort of the and queer people. As part of like the, the core set of characters doing really important things. And yeah, I, and I just find that so amazing to read, but also the story is just so, it's just a cracking story. And kind of epic and yeah, I just loved it anyway. 

Brianna Miluk: What is it called? Orange and the Prairie. 

Dr. Katherine Sanchez: Priory of the orange tree. 

Brianna Miluk: Priory of the orange tree. Okay. 

Dr. Katherine Sanchez: Priory. A priory like like where nuns and stuff might hang out.

Brianna Miluk: Oh, okay. I was like prairie? 

Dr. Katherine Sanchez: Prairie? House on the prairie? 

Brianna Miluk: How would you transcribe it in standard American English? Okay, my next question is- 

Dr. Katherine Sanchez: We have a non rhotic R right? Priory. 

Brianna Miluk: Yup, yup. Oh my goodness. Okay, next question is, What is it? Cause you're in Australia and I'm coming to Australia in March, which I'm so excited about, but what is a snack that I need to try while I'm there?

Dr. Katherine Sanchez: Oh, okay. Like the classic one is Tim Tams. If you come to Australia. 

Brianna Miluk: Okay. 

Dr. Katherine Sanchez: So, they're this they're biscuits. They're like like layers of wafer and they're chocolate covered and they're really delicious. And like the FIFA Women's World Cup, I, I saw this video of like all of the Australian women like coming out after a match or I dunno, for a PR or something and an Australian out there, like giving them like a salute and then opening their hand to reveal that they had a wrapped Tim Tam and like all of the Australian like, Ooh, yeah.

Everyone loves a Tim Tam and you can do this thing called a Tim Tam Slam where you bite each end of the Tim Tam and then like suck a sweet drink through it and then it makes the inside all like mushy and delicious and then you eat the Tim Tam. So good. 

Brianna Miluk: That sounds so good. Okay, I'm excited to try that one. 

Dr. Katherine Sanchez: Also, Fairy Bread, you should try Fairy Bread.

Brianna Miluk: I have been dying to try Fairy Bread ever since I saw, who was it, was it Holly that posted it one time? I think there was like a birthday and I was like... What is Fairy Bread? 

Dr. Katherine Sanchez: It's so good. 

Brianna Miluk: I'm very excited. 

Dr. Katherine Sanchez: It's the taste of an 80s and 90s Australian childhood. And then I know you only asked one, but I will say that I brought over some Australian treats to America last year and some of my workmates tried them and they were all very into Lamingtons. So even though that's not what I would have picked, maybe you want to try a Lamington, which is like, it's like a sponge cake with jam in it. And the outside is covered in like chocolate and and coconut. 

Brianna Miluk: That sounds delicious. So, I might, I think I'm going to need to try that. I think- 

Dr. Katherine Sanchez: Yeah, you've got like a top three list. Come to my office and I will serve you just a dinner of Tim Tams, Fairy Bread, and Lamingtons. 

Brianna Miluk: That sounds perfect. That sounds perfect. I love it. I love it. Okay. Is there anything else, any other closing points you want to bring up that you feel like we didn't hit on? I feel like we got. 

Dr. Katherine Sanchez: I don't think so. And I'm so happy that we had that digression into talking about therapy notes, because it's something that I hadn't even thought to talk about, but now I'm obsessed and I'm going to talk to- 

Brianna Miluk: And I'm obsessed now. Now I'm, I'm like, going to go like review every note I've ever written. I love it. Well, thank you.

Dr. Katherine Sanchez: *Talking at the same time* -interesting. 

Brianna Miluk: I know. I know. Well, thank you so much for chatting with me again. Every time we talk, I learn something new and I appreciate that so much about you. But. I hope that you all enjoyed listening and till next time. I'm sure you'll be back. You'll be back.

Dr. Katherine Sanchez: Oh, I'll be back, I'm like a boomerang. You can't get rid of me.

Brianna Miluk: I know. I love it. Thank you. 

Dr. Katherine Sanchez: Thank you. 

Brianna Miluk: Thanks for tuning in to The Feeding Pod this week. If you enjoyed today's episode, please don't hesitate to share this podcast with your friends and colleagues and leave us a five-star review wherever you're listening from. If you're interested in learning more about pediatric feeding and swallowing, be sure to follow Bri, me, on Instagram @PediatricFeedingSLP, or check out my website where you can get access to more courses and information, www.pediatricfeedingslp.com. Again, thanks for being here and listening to my ramblings, and I hope you'll keep listening. Until next time, cheers.

 

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