EPISODE 256

[INTRODUCTION]

[0:00:14] MD: Hi, folks, and welcome to First Bite: Fed, Fun and Functional. A speech therapy podcast sponsored by speechtherapypd.com. I am your host on this nerd venture, Michelle Dawson, MS, CCC-SLP, CLC, the All-Things PFDs SLP. I am a colleague in the trenches of home health, early intervention right there with you. I run my own private practice, Heartwood Speech Therapy here in Columbia, South Carolina. I guest lecture nationwide on best practices for early intervention for the medically complex children. First BiteÕs mission is short and sweet, to bring the light, hope, knowledge and joy to the pediatric clinician, parent, or advocate.

[0:01:01] EF: By way of a nerdy conversation, so there's plenty of laughter, too.

[0:01:05] MD: In this podcast, we cover everything from AAC to breastfeeding.

[0:01:10] EF: Ethics on how to run a private practice.

[0:01:12] MD: Pediatric dysphagia to clinical supervision.

[0:01:16] EF: And all other topics in the world of pediatric speech pathology. Our goal is to bring evidence-based practice straight to you by interviewing subject matter experts.

[0:01:25] MD: To break down the communication barriers, so that we can access the knowledge of their fields.

[0:01:30] EF: Or, as a close friend says, ÒTo build the bridge.Ó

[0:01:34] MD: By bringing other professionals and experts in our field together, we hope to spark advocacy, joy and passion for continuing to grow and advance care for our little ones.

[0:01:45] EF: Every fourth episode, I join them. I'm Erin Forward, MSP, CCC-SLP, the Yankee by way of Rochester New York transplant who actually inspired this journey. I bring a different perspective, that of a new-ish clinician with experience in early intervention, pediatric acute care and non-profit pediatric outpatient settings.

[0:02:05] MD: So, sit back, relax and watch out for all hearth growth and enjoy this geeky gig brought to you by speechtherapypd.com.

[INTERVIEW]

[0:02:20] MD: Okay, everybody. We are full swing, getting ready for ASHA, and weÕre, bloody hell, probably only six weeks away by the time you're listening to this. I'm looking forward to seeing everybody in Boston, and we're going to tease out from there.

Today's guests are part of Erin and I's efforts to expand our interprofessional education to grow our interprofessional practice. I know that a lot of y'all listening don't actually conduct swallow studies, right? I mean, some of you may, but a good chunk of us don't have that opportunity, because there's just so many hospital SLP opportunities available, right? But we're still the ones that are encouraging and giving the recommendations to the caregivers that their child may need an instrumental swallow evaluation, which that can be a hard sell at times.

We're here today to help you make that easier and deport evidence into your caregiver coaching. Without further ado, Erin and I have the joy of introducing Caroline Brindo, MA/CCC-SLP, BCS-S, who's currently the Head of Varibar with Bracco Lake, like taco, not Braco. So, Bracco like taco Diagnostics, Inc. She is a board-certified specialist, and she does a ton of stuff behind the scenes, and you might have caught her previously on Swallow Your Pride. If you haven't, well, she's done a couple of episodes with Swallow Your Pride, so go let her grow your evidence-based triangle. But she will be, for sure, at ASHA, working a booth. And her partner in crime for the day, Erin, help me, because IÕm going to do it wrong, is Dr. Steven Sireci.

[0:04:16] SS: Yes.

[0:04:18] EF: There you go.

[0:04:18] SS: You got it.

[0:04:19] EF: I thought you were going to try the Italian version.

[0:04:22] MD: Well, I froze, because I was like, ÒOh, my God, is it Sirechi, or Serichi,Ó because we had this big, long conversation on the origins of names, and I couldn't remember if it was the Sicilian, or the Ð Anyways, we geeked out, y'all. We geeked out. Dr. Steven is the Executive Director of Medical Affairs, who serves as the Head of Medical Affairs for America's, for Bracco. I butchered that. It's been a long day. Bear kept me up. I blame the boo Bear. He's currently working from home, but he helps support the scientific communication and education for Bracco's Varibar product line, and just basically, growing people's awareness about what's in the barium sulfate that we were consuming.

He received his MD from the University of Medicine and Dentistry in New Jersey, before going off to work in various settings, including Columbia Presbyterian Medical Center in New York, as an assistant professor of radiology. Y'all, these folks know their business. Hi. I play with tiny humans. We eat, and it's great. There it is.

[0:05:35] SS: Sounds like you have more fun.

[0:05:37] MD: I really donÕt, but you're in [inaudible 0:05:38] and queen of play. Just saying.

[0:05:45] CB: Awesome. Well, thanks Michelle and Erin. I'm excited to be here. I'm sure. Dr. Sireci is as well.

[0:05:54] MD: Well, thank you for coming on. Can y'all take us from the top? Caroline, can you tell us what made you want to be an SLP, and then one who focuses in this sub-sub-sub specialty?

[0:06:06] CB: Yeah, sure. It's a great job to talk about a party sometimes, and explain what I do to people I meet. Yeah. I went into grad school. My mom is a teacher, and I wasn't sure what I wanted to do, and she suggested speech therapy. I went in. I did my undergrad at the University of Akron here in Ohio, and then I went on to grad school, and I did a student teaching-based placement. It was really challenging. I had 93 kids on my caseload. I was at five different schools, and I just thought, ÒI don't know if this is something I can do.Ó Then the very next semester, I took a class in dysphagia, dysarthria, and apraxia, because at the time, you didn't really get a whole of that.

[0:06:53] MD: Wait. All in one class?

[0:06:55] CB: All in one class. Yeah. You didn't get a whole class in dysphagia, just like a third of a class at the time. I really loved the dysphagia part of it, and then I'm going to date myself even further here, but one day, the professor brought in VHS tapes of modified barium swallow studies of adults and infants, and I was just blown away. I was just really fascinated by them, and I actually went up and I asked him if I could take the tapes home with me. He laughed, but he also let me, which was great. I took them home and I watched them all weekend, and I was just Ð I've just always been fascinated with modified barium swallow study.

Then my first job, I took at a hospital. It was a small rural hospital here in Ohio. They had five other speech pathologists, and they were awesome, but they had just started their swallow study program, basically, and none of them really enjoyed it. It wasn't their interest level. During my interview, I just went on and on about how much I loved them, not knowing they were looking for somebody who liked modified barium swallow studies, and they hired me. I was really lucky to get that job from my fellowship year just right out of school in a hospital learning and training on how to do swallow studies.

We had a infant feeding program there, so I did all. I started training and learned how to do all the infant and swallow studies, and did all of our adults and outpatients. Since then, I've done just a little bit, almost everything that you can do as a speech pathologist, but always with a focus on dysphagia and the modified barium swallow study. I've done a little bit of home health and inpatient-outpatient rehab. I've done Everton skilled nursing facilities. I worked for years for a mobile modified barium swallow study company.

Then I started working for Bracco about six months ago. My predecessor, Julie Peterson, also a speech pathologist, did a wonderful job. Retired and they were looking for someone, so I just jumped on the opportunity and here I am. That's my little swallow study story.

[0:09:14] MD: Nice. I want to know, have you ever seen a mega esophagus, or have you ever seen Ð I heard it called a corkscrew esophagus, where it goes around?

[0:09:25] CB: Yes. Yeah, for sure. I actually, in my prior job with a mobile MBS company, I started and wrote a blog called Modified Monday. There's a couple. If you look up Modified Monday, it's on there, but there's a mega esophagus, there's a corkscrew esophagus. Yeah, I got to see a lot of interesting things over the last, it's not years of doing modified Ð

[0:09:50] MD: We are Botox-friendly here. You're in good company. That's okay. Erin is not Botox-friendly, but I got you covered. Okay. Well, Dr. Steven, yeah, tell us your journey. How did you become a physician and also in radiology, because that seems very Ð I heard a scary story about a study that was done on gorillas and CT scans, and how often a gorilla inserted into a CT scan is missed. Now, I'm worried about radiology as a general rule of thumb. But hi, how are you? 

[0:10:26] SS: I haven't had the opportunity to scan any gorillas.

[0:10:31] CB: Missed opportunity.

[0:10:35] SS: Well, I mean, I guess, I always wanted to be a physician. Then you get to medical school, and then a little later on, you realize that that's only the beginning. Well, now you have to pick what kind you're going to be. You go through your various rotations, surgery, medicine, obstetrics, college, etc. I went through all the basic ones in third year, and I was still undecided. I had to do electives in fourth year. I came upon radiology simply, because I liked the idea of solving unknowns, I think. You're presented with what's going on with this person. You have to put together in your mind, what it is you're seeing on the imaging study and come up with an answer. I like that sort of thing.

When I went into practice, I found the day-to-day of it to be not exactly what I was looking for for my career. It was difficult. And for me to deal with the conditions of work. It's one thing to say, I like what I'm doing. It's another thing to like the conditions of being a radiologist in a hospital. I looked for change, and I went into industry, and then that became my career. I've been in industry over 25 years now, and I've supported a whole bunch of different products in different settings and got assigned our Varibar, our product for the MBSS a few years ago.

I figured out early on that one of the real needs was that people don't realize what goes into making a barium sulfate product and how they do what they do and why they're different from each other and what you should use and why. That became my educational focus in my support to the product. That's been fun to do.

[0:12:32] MD: That's huge. I have nothing to do with swallow studies. I mean, I've participated in a few a couple of times, but I don't want to work in a hospital. I don't do well in confined spaces. That's an understatement. Yeah.

[0:12:50] SS: Well, the radiology department is not for you.

[0:12:52] MD: No. Definitely, itÕs not. But Erin on the other hand, she actually does the swallow studies. Erin, can you Ð for folks that aren't in the room, as the SLP, can you describe for us what that experience is like? Because when we're coaching caregivers on, ÒHey, we don't need to be able to go do this,Ó we get the pushback. Can you walk us through what it looks like, because it can be scary?

[0:13:20] EF: Well, and I will say, I work at Cincinnati Children's. Because I've been there since January and I tell my co-workers who have been there forever, I'm like, ÒI don't think you guys realize that this is like a bubble of collaboration that is not at every hospital, like the way the collaboration with radiology and how we support each other.Ó I do as well City Clinic, where there's two of us. One of us does intake, gets the patient ready while the other one's getting all the barium and everything set up for the study.

I know how lucky I am, because I work somewhere else where we did everything and there wasn't as much collaboration with radiology, but I'm lucky in that I see patients in outpatient and then we'll also see them for swallow studies, so I get to talk patients through and families through what's going to happen when they get to the swallow study, because especially our kids who have had a lot of procedures and get a lot of X-rays, they walk right into the room and they're like, ÒOh, no. This is not happening.Ó Then you have to get them to voluntarily eat, which two-year-olds, I think, are the hardest patients to do swallow studies with, because they're old enough that they know they don't want to do it and young enough that you can't really negotiate with them. There's no negotiation.

[0:14:46] MD: [Inaudible 0:14:46].

[0:14:50] EF: Yeah. But I always tell my families, you come in, you get to sit in a chair that looks Ð it looks like a rocket ship, if you really think about it. My kids get to decide where they're going to go to in this rocket ship. Then, because you pull out the screen for Ð they're sandwiched in the middle of it, but I'm like, ÒNothing will touch you. Your parent can stand in front of you. You get to eat the food and drink the liquids. Then we're all done.Ó Which sounds a lot easier to explain them when they actually get into the room, because you also have the radiology tech that's behind the screen. You have the machine. I don't know all the technical terms of the pieces of the radiology machine, but it's huge. It's scary for kids, because they don't know what to expect.

We actually have talked about, because we do, we have a PFDs coloring book for kids that get PFD studies. We've talked about wanting to create a video for kids, showing them what's going to happen before they get there, because so much of the fear is the unknown and not knowing ÐÒYeah, you say it's going to be okay, but the last time you told me this was going to be okay, I got a shot and then somebody did this to me, so I'm not really sure.Ó Yeah.

[0:16:07] MD: That helps. That helps. Because I'm just imagining, I've had to hog tie Bear down a few times for ultrasounds. Carline, Steven, y'all don't know, Bear is my youngest and the eight-year-old that was up all night with the leg cramps. When we are doing our assessments and we're actually utilizing our products, once upon a time, I did do instrumental swallowing evals on adults. This was my CF in the first year out. That was a lifetime ago. I had a pitch to bring in the equipment to the board of directors for the hospital system. It was a very rural hospital. Riverside, Walter Reed and Gloucester County, Virginia. That was too many years ago.

When I had to make my pitch, I had to research the chair, the rocket ship. I had to research what products that we needed to administer during the instrumentals. Thank God, Dr. Bonnie Martin-Harris had just started all of her publications, because I took every course I could get my hands on and researched so much of her work in making my literally a brief and a pitch. I think back, did we select the right product? Did we select the right materials to administer? Because I didn't know. I still don't know. Can you talk to us about what goes into the product structure, Steven, and what makes it the right item versus maybe one with a lower resolution, or whatever that may be?

[0:17:46] SS: Sure. Technically, in terms of radiologically, what you actually see on the images, you want a particular concentration of barium sulfate. It's really the barium that matters. That's what blocks the X-rays. You want a particular concentration of barium in the mix that's right for this part of the body, that's right the oropharynx and the upper esophagus here. Radiologists would tell you, this is a tricky area because you're going between the larger head and the much larger thorax and the fluoroscopy machine is literally changing the technique, the radiographic technique, as different densities come into the field of view. It's a tricky thing to get the radiographic technique just right in the neck and to get the barium to be at the right concentration for that area, while also being visible here and a little bit lower. What was worked out for the products that we make that are specifically for the modified barium swallow is that it's 40%. 40% weight to volume is the barium sulfate concentration. That is the Ð

[0:18:58] MD: What does mean, weight to volume?

[0:19:01] SS: The weight of the literal barium sulfate, the powder that's suspended in there versus the volume of fluid it's suspended in. 40 grams per 100 milliliters, whatever, that's the percent. That literally tells you how much solid is suspended and how much liquid. The solid is what's blocking the X-rays. Now, the solid's tiny particles. It's very finely milled and emulsified, so that it spreads out. That's what you're looking for to block the X-rays just right in that part of the body.

Much higher than that and you're going to get Ð it's going to look too much like liquid lead and it actually obscures some of the things you're looking to characterize. Too light and you're going to have trouble seeing it, particularly in the denser areas above and below that little stretch of neck. You want to get that concentration in the right range and 40% seems to be in the right range, so that's all of our products, no matter how thick or thin they are, or 40% with the barium sulfate.

Then the other thing that makes a product right for the swallow is based on what you need to get out of the swallow. For instance, you don't want residue if it isn't really there. You're looking to see whether some of the barium gets left behind in the throat when the person's swallowing, that's not a good thing. There are barium products that are made with sticky gums, whose purpose is to get left behind, stuck to the wall of what you're looking at, because that's what you're trying to do. You're trying to see the detail of the wall looking for ulcerous tumors, whatever.

You don't want to use that kind of a barium that has the sticking gum in it. Usually, the product uses acacia gum. The acacia tree is that huge African tree that the giraffe's eat from. Well, it's that produces a gum, which is very good at sticking the barium particles to the wall of the inner lining of your GI tract. You don't want that in the product. Also, if you have a high concentration of something called carboxymethylcellulose, which is modified cellulose, plant fiber, it will also, using, actually, electrical attraction between positive and negative charges, will also stick the barium particles to the wall. You don't want that either. You have to have the barium mixture made so that it won't stick to the wall.

 You also want it to be made to a particular viscosity, thickness. People call that consistency also. You want several different ones so that you're testing swallowing under different challenges, from thin to a pudding. You want to give the same challenge to every patient and to each patient every time they come to an exam, so you're consistent from test to test. We have to formulate it to make a particular viscosity. That requires putting in thickeners that are not sticky thickeners, but non-sticky, like starches. There are starches. Now, one of the ones that's really common is xanthan gum, which people use in baking. You could have that in your kitchen bags as xanthan gum.

[0:22:20] MD: That's some thickeners for the compensators. Yes.

[0:22:24] SS: Right. Yes. Right.

[0:22:26] MD: Necrotizing enterocolitis.

[0:22:27] EF: ItÕs simply thick.

[0:22:28] MD: Age one in a 100.

[0:22:30] EF: ThatÕs the product that had a lot of controversy with kids with that.

[0:22:35] SS: Yes. But it's an essential ingredient in barium, because not only does it provide the thickness you're looking for in barium preparations, it also is an emulsifier that keeps the particles suspended in the water. If you just took barium sulfate, milled barium sulfate, the rock, milled up into powder and threw it in water, it would go right down to the bottom of the container and sit on the bottom, like sand on the bottom of the ocean. You have to keep it in the liquid suspended. You need other things to do that. Xanthan gum is an excellent thing for doing that, actually. The xanthan.

You need that thing. You need these emulsifiers, suspending agents. You also need flavorants. You need texturizers, things like maltodextrin, which provide mouthfeel texture. It's a real recipe. It's like making food when you're making a barium product. It really is. ItÕs baking? I mean, sort of. Depending on how you make your recipe, you're going to have a product that's going to give the test you want to give, whether it's thin liquid, or something like honey, or something like pudding. That's based on all these other things you throw in with the barium, because the only thing the barium does is block X-rays. It doesn't do any of the rest of it. You've got to make the right recipe, or you're not going to get the right test, or a consistent test for patients.

[0:24:02] MD: I literally thought barium I made you glow. I didn't realize it blocked the X-rays.

[0:24:07] SS: Yeah. The X-ray is Ð

[0:24:09] CB: It is not radioactive.

[0:24:11] MD: I'm still processing that. And the tree thing. The trees with the giraffes. What does that Ð Okay, that's how I remember an analogy [inaudible 0:24:19].

[0:24:19] SS: Okay. Yeah, I know. ThatÕs why I say it, because Ð

[0:24:22] MD: Would that be used in an upper GI, or a lower GI?

[0:24:26] SS: Yeah. That's right. That's usually very high density. You use very little of it. You use gas, or air with it as well to fill the lumen, right? The only barring you should have is stuck to the walls and then inside of it is the air. Then that's called a double contrast barium study. That is absolutely not what you're doing in the modified barrier swallow. You do not want that kind of a barium product. It will create the appearance of residue. It'll be too dense. It would be a disaster, actually.

[0:24:58] MD: I had no idea, there was two different products for different Ð

[0:25:01] SS: Oh, thereÕs more than two.

[0:25:03] CB: Oh, many products. Yeah.

[0:25:03] MD: Yes. I mean, like two. But that's still so cool to me to be able to understand that, ÒOh.Ó

[0:25:14] CB: Yeah. That's, and for my piece Ð Sorry, Dr.  Sireci.

[0:25:17] SS: No, go ahead.

[0:25:18] CB: I was going to say, for my piece, that's what I spend a lot of time talking to clinicians about is that Ð and actually, all of these products that we're talking about, they're all Brocco products. They're all great products for their procedure. These are all great products, but there are so much that goes into the formulation of these various barium sulfate products for a good reason, because you're making them for a very intentional procedure. For a modified barium swallow study, we need the formulation to be a certain way for really good reasons.

[0:25:57] SS: You had said before, you thought that barium makes you glow. Now there is a range of imaging that does that. That's nuclear medicine. There, they inject the radioactive into you, and then you radiate them outward and the camera is a passive camera that just receives the information. In this, barium is blocking X-rays. Other X-rays are going right through you to the electronic plate behind you, which is then acquiring the picture. The thing that you talk about that's scary to the kid who's sitting in the chair is what they're looking at usually, and that's called the tower. In there is the X-ray tube that's actually firing the X-rays through the patient. The barium is just there to block X-rays, so that that part sticks out on the images and you can evaluate what it is you're seeing.

[0:26:47] MD: My question is, Erin, what does it look like when you're the person prepping this? Because it's been a minute. When you're prepping and mixing, what does that look like?

[0:26:59] EF: Well, I'm very curious to learn from you guys, because thinking about the recipe and especially in pediatrics, because we say to the kid, ÒDo you want to eat?Ó They say, ÒNo.Ó It's not like I can negotiate with them for, ÒYou better drink this, or you're not going to be able to eat.Ó Most of the kids I see don't even want to eat. We have to find ways to make things more enticing. Now I'm like, what is it doing to the solution? Sometimes they'll add powdered chocolate to make it taste better. Or, well, my favorite, the best one to do is to use an Oreo, because you can hide the Varibar paste in it. But still, then your solids are really hard, because you Ð especially with kids, because you can't Ð if you put the paste all over it, it doesn't look the thing they're trying to eat.

Thankfully, most of what we're concerned about usually is liquid. If it is more of an esophageal concern with solids, then we can send them to further assessment that's going to look deeper at that. We do use Varibar products where I am. I always prep the consistency that they're already consuming to make sure I can try that. It depends. I like to get multiple consistencies ready, so that I can assess that with them. I think with the younger population, with infants too, it gets very tricky. I know there's some research coming out in regards to, especially with nipple flow rates, what is a thin liquid in a Dr. Brown level three, versus a mildly thick liquid in a Dr. Brown level four?

It depends, again, on what the physiology of the swallow is and why they're having difficulties, which is what the swallow CT is going to tell us. Yeah, we use all Varibar products. We try to get our liquid set up in whatever modality they're using. Then we use both the barium paste and the powder for solids. I honestly, thinking about it too, don't know the best recipe for the powder with solids, because sometimes I'm like, ÒIs this too much? Is this too little when you're mixing it with puree?Ó

[0:29:36] MD: That's what I remember. I felt like, it was just Ð I felt like I was using the red pepper flakes from Pizza Hut. I remember the Pizza Hut book logs. I am not too old for those. If you read so many books, you got a free pizza at Pizza Hut, but the red shaky powder, or the Parmesan cheese, that's what I think of.

[0:29:56] SS: Yeah. We hear from clinicians all the time that are doing all kinds of different things. I think, for me personally, as a field and I've been doing them for a long time on the entire age range spectrum, we know that there are many, many things that we don't know about dysphagia, about what is normal, about what's not normal, about the impact of dysphagia, the impact of thickened liquids. There are so many things that we don't know.

For me, what I try to do as much as possible is rely on the things that I can standardize, the things that I can make standard every single time. That's where I come back to. Varibar is, it is standardized. We have this 40% weight by volume. We know that it's formulated for the swallow study. Coming back to that and using that standardized product, because that way, I know that at least that the data that I'm gathering during that modified barium swallow study can then be compared to other data that's using that standardized product, right? Because, like Dr. Sireci said, it is so Ð and in fact, Varibar was born from clinicians asking for standardization.

When Dr. Jeri Logemann and Dr. Joanne Robbins, when they were starting to work on protocol 201, they realized that their research was going to be flawed, because they couldn't Ð they were looking at multiple institutions to gather the data for them and gather and do the swallow studies. They're like, everybody is using these different recipes, these different shaking powder, like you were saying on one thing, or mixing powder with apple juice, or whatever. They realized that they couldn't really capture good data. They are the ones that actually approached a company called EZM in Canada, who was later acquired by Bracco, and said, ÒWe really need some help creating a standardized product for your research.Ó EZM in my mind were like, ÒYeah, great idea. Let's do it.Ó Then it just happened. That's where Varibar actually [inaudible 0:32:11] Varibar came to be.

Then, the clinicians then that we're using this standardized product, because of all of the other variables that we Ð the things that we don't know about this dysphagia, being able to use this to gather that data was just really critical. Just a couple of years later, Varibar was made commercially available, because of that demand. Yeah, go ahead, Dr. Sireci.

[0:32:39] SS: No. I mean, a lot of decisions in healthcare about how you're going to treat patients for all sorts of serious illnesses and expending how you're going to expand the health care dollars, which are enormous, are based on huge studies. The only way you can do them is everybody's doing the same methodology, so that you can compare large bodies of data that come from multiple places everywhere, because everyone did the same thing.

Now, not all the patients are going to be the same. That's pretty much impossible. You can make all your methodology standard, so that at least, you have comparable data from different places that you bring together into huge databases that are very statistically significant and whose results can be used to guide healthcare practices, as well as guide reimbursement.  We all are interested in that, and Medicare likes to see big data. That's called big data, literally.

You can't have big data if everybody does the procedure their own way. There's no such thing, because there's nothing you can put together that makes any sense if everyone's done the procedure differently.

[0:33:50] CB: Right. I think that applies just as well to clinical practice and reassessing, and assessing the progress of a patient, or lack thereof. Again, every single study I see it, or complete with a patient, it just drives home how important that study is and how important doing it correctly is. Because we see over and over and over again that a patient was judged to have declined, or improved. But then, when you go back and you look at the prior studies, or whatever, it's really like they're completely different studies, because once it was done with a certain procedure, or a certain way, and then the next study was done a completely different way.

It's a new field. It really is a relatively new field. We're learning more all the time about how to assess and how to treat. This is just one thing. I feel like, we've got this nice, standardized product and it's just a way to take away some of that variability that we see so much of in our field.

[0:35:11] MD: Well, go ahead.

[0:35:13] EF: I was going to say, to your point, I think what becomes difficult is thinking about what information we're trying to get and how we're measuring that, because oftentimes, and in coming from two very different experiences of doing swallow studies, one where I feel very supported within the collaboration of the team, and another where there was not as much collaboration, and I felt like I was on this island making all these decisions myself. The decision making was so drastically different, because when you don't feel like you have that collaboration and support, I think the decision, some of the decisions get clouded by maybe being a little more conservative, which I don't truly believe in being conservative, because we have to allow people to show us what they can do.

Your point of what are we measuring, if we're so focused on looking at which those of us who do swallow studies will tell you all the time, we're not looking just for aspiration, or penetration. We're looking at what their swallow looks like. We're trying to also look at that within the big picture, because that's another thing is that how is this child or person presenting? What is their history? I think there's so many times where people will do a swallow study and it doesn't really match up with what's happening clinically. That does happen sometimes. Those are things that sometimes we see via X, right? Just because we can't observe everything behaviorally.

Also, how are we trying to set them up for success, too? Because if we're constantly trying to look just for the ailment, as opposed to how we can support them, I think that poses a difference within how we're conducting those studies as well. With kids, it just does become so difficult as well. The people listening to this podcast, most of them work in pediatrics. We have a lot less data there. We have to pull from the adult literature. But also, there's so many factors involved. We want to make it look as similar to what they're doing at home, but we also want to make it standardized. I find that's the hardest thing for me to collaborate, because it's like, if I'm going to get them to do this more independently by putting some chocolate in there, is that more important? Or is it more important for it to be more standardized, if that makes any sense? How am I matching those two things for this individual patient and also, for the next study they do, or what we're looking at overall?

[0:37:58] MD: Wait. Here's my question. Is there a set recipe Ð is there a recipe that when you're going in to try a IDDSI level seven on an Oreo, is there a certain volume of barium paste to Oreo, you see what IÕm saying? Or is it a free for all?

[0:38:23] EF: Very good question.

[0:38:24] SS: There is, Michelle, a set recipe, and that's in our five different Varibar products have set recipes. Now, in terms of what you're looking at is this called the solid phase. The solid that you're giving the cookie doesn't have barium in it, so you want to know, I mean, how much pudding do you put on it? By the way, it's putting you want to use not the paste. There is a difference. Yeah, the paste sticks. It's got some of the stick Ð

[0:38:56] CB: Yeah. It does stick.

[0:38:58] SS: It will give you the appearance of residue. You want to use the Varibar pudding as the thicker thing that you put on the cookie. I guess, you basically just put a bit of a schmear on the on top of the cookie, and because itÕs there Ð

[0:39:14] MD: But when the schmear Ð thatÕs Ð

[0:39:16] SS: No, no. See, there, the amount that you're using is only Ð it's just enough, so that the radiologist can see the solid fragments going down, how they're being processed, chewed and going down. There, you're not worried about viscosity, because you're actually testing a solid and the concept of viscosity is for liquids. When you're testing a solid, you don't worry about the viscosity of the pudding, versus the solid, because it's not an issue. What you're worried about is getting enough on there that the radiologist can see as it's being chewed and going down, can see that the fragments are marked. The solid fragments are marked as they're being chewed up as well. There may just be a little experience involved in doing that.

[0:40:03] MD: Okay. Then to get back to the schmear part, that was the part that I worried about was, are there specific recipes, Caroline, that we have to follow? I say that if I actually do this, I don't, that SLPs working and doing this have to follow when they use Varibar.

[0:40:20] CB: Yeah. I mean, honestly, that's a great question, because that is the beauty of Varibar is it is commercially prepared. It is ready to go for the modified barium swallow study. The only exception is our Varibar thin. It comes in a powder form. They're very specific instructions. It tells you exactly how much water to put in there. How long does Ð to let it sit there, to reconstitute it into a thin liquid. But the nectar, thin honey, the Varibar honey and the Varibar pudding, they are ready to go. You just squirt them out. You don't mix them with anything. Then that's your standardized product. They're ready to go.

That way, when we're doing these swallow studies between clinicians, between facilities from patient to patient, we don't have to worry about that unstandardization. That is a standardized product. You know that that patient is always going to have the 40% weight by volume, the same opacity. They're going to have the same viscosity, because everything has been poured out exactly commercially prepared and as it is, and that's how it is.

[0:41:32] MD: You use the National Dysphagia Diet terms. If a hospital has switched fully over to IDDSI, are there directions to adhere to the IDDSI level?

[0:41:39] CB: Yes. Yup. Dr. Catriona Steele did a beautiful work of mapping the Varibar products to the IDDSI standards. It is publicly available, and I can send you that information and you can include that in the show notes.

[0:41:54] MD: Yes, please. That would be excellent. Okay.

[0:41:57] EF: I did have the SLPs I work with where like, do you know if they're going to make a slightly thick consistency? Because I know that you have the recipe, but they were like, ÒThat would be ÐÓ I don't know. I'll ask them.

[0:42:10] CB: It would be great. Yeah. We do get questions like that. We get questions like that all the time. We also get questions about a Varibar solid, because we don't currently have that. Yes, we get questions about that a lot. We take all those questions and we Ð I was actually just up this past summer in Montreal at the facility where Varibar is made, and we discuss where are we going next? What's happening? Yeah, so if there are suggestions or questions, always bring them to our Varibar team.

I'll just throw our email, or our website out there is varibarmbs.com. There's a little Contact Us button on there. Everybody, all those come directly to me. Any suggestions or requests, we are always thinking and always looking.

[0:42:57] EF: Well, and after you guys have talked about everything that goes into it, it makes us realize how it's not just that easy to make a whole new product. I think that will help people understand that it's not that easy to switch over to something new, or change everything.

[0:43:15] MD: Okay. I have two questions. One, can we talk about the radiology, the radiation component of this? Then just general question that I always get asked, and I don't know if y'all are the people to answer this, but if you're not, you could maybe send us to someone who is. How does this impact their poop? What happens when they Ð Seriously. I work with patients that have constipation and poop is Ð or will this impact their urination? I mean, I have some patients that only have one kidney.

[0:43:51] CB: So many things to consider.

[0:43:54] EF: Especially when you work with infants. I have a lot of new moms that come in that are anxious, that are like, ÒI'm worried about the radiation exposure. I'm worried about ÐÓ It's hard to always know what to say sometimes, because you don't know what their journey is going to be.

[0:44:10] CB: Yeah. Yeah, exactly. I'm going to pass this, obviously, to Dr. Sireci in a minute here. Yeah, it's a genuine consideration. Radiation in little ones is really something really important to consider. It's not just that they're more susceptible, which Dr. Sireci, I'm sure will talk about. There's a good chance that they're going to have a lot more radiological studies in their future. They have a longer life ahead of them. Considering their total radiation exposure should really, really be considered.

Yeah, if we're going to expose them, though, to radiation, we want to make sure that it has to be worth it, that weÕre getting data that is worthy of that exposure. We still want to make sure that we are adhering to our gold standard. It needs to be either 30 pulses per second, or continual, but is just maybe even more Ð

[0:45:00] MD: Wait. Translate that, Caroline.

[0:45:02] CB: I'm sorry. Yup, so Ð

[0:45:04] MD: I'm 30 seconds through what is happening now?

[0:45:09] EF: ThatÕs a good debate, Michelle, in the world.

[0:45:14] CB: When you're doing a fluoroscopy, it's motion X-ray. You have some choices. You can do continual, so that means the X-ray is going continuously, right? Or it can pulse out little pulses of X-ray. The minimum gold standard for swallow studies is 30 pulses per second. Because we know that with a lower rate, so some of the other settings that you do on fluoroscopy are 15, or even seven, there are lots of studies that show that our ability to capture specific swallow physiology movements is not as good with those lower pulse rates.

[0:45:59] MD: Okay. That's critical information. Thank you. Okay, continue. Sorry.

[0:46:04] CB: No problem. That's okay. What I was going to say is the other part of this is again, we need to make sure that if we're exposing them, that it's worthy of exposing them to radiation. Using homemade recipes and a little bit of this, a little bit of that can do a couple of things. It can make the study useless because you're not capturing the right data, or you can't see what you're supposed to be looking at. Or it can make the study deceptive. Deceptive means that you have a recipe that facilitates coating of the pharynx. Then you think that there's an impairment there, because there's a coating. The coating is supposed to be there for that product. That's why it's so important for Varibar that it not leave that coating.

Again, the inconsistency between studies. If you've got one study that's using one recipe, one product, it can look very different than another study that's using a different product. Then you have this false data that you're comparing to know if a patient is making progress, or not. Then the other part of it is it can be useless. You can end up with not enough opacity to even see what you really need to see, the swallow physiology.

I have this one kiddo that really sticks with me, when I was doing infant swallow studies at one of my first jobs. The radiology technologist had mixed up a recipe using a barium sulfate product. We had done all this work to get this baby in the tower and got the bottle and the baby was calm enough to eat and then started with the bottle and a couple of swallows in, I realized I couldn't see anything. It took me a couple more seconds to convince the radiologist to stop and turn off the radiation and the radiology technologist had just not mixed properly. I couldn't see anything. The opacity was so poor.

It just really has always stuck with me, because I just felt so awful that that baby had been exposed to radiation for no reason. There was nothing that I could see and I couldn't do anything with it with those images. Again, it just really drives home that we need to make sure that we are using the standardized preparation that is intended for the swallow study.

[0:48:38] SS: Obviously, you're more concerned with radiation and children for two reasons. It's that the cells in the body that are susceptible to radiation are the ones that are actively multiplying, making new cells. That's when they're really, really susceptible to radiation causing damage. With the little ones, all their cells, it seems, are multiplying and growing and making more cells. Whereas, in an elderly person, not so many. There's certain ones that are, but many of them are not active.

Basically, the little ones, their entire bodies are susceptible, much more susceptible to radiation damage than say, an elderly person, many of whose cells are just quiescent, not really doing anything. The other problem is that radiation effects tend to be longer term, right? The medical radiation is, should never give you a dose that's going to give you an immediate radiation sickness. The things we worry about are long term. Well, if you're giving radiation study to an 80-year-old, there may not be a long term. There generally isn't a long term. By long term, I mean 20 years, whatever. You don't worry about it.

With a little one, you worry about it. They're going to live long enough that not only has Caroline said, are they likely to get more studies over time, if they have an ongoing condition. They're also going to live long enough that the long-term effects of radiation are going to have a chance to exhibit themselves. You really do worry about it in children.

The question you always have to ask yourself is if the risk is worth it, given the risk of not dealing with the problem, which is why the child is in front of you anyway, needing some kind of an evaluation, or treatment, right? A healthy kid with no problems doesn't get this study. You always have to weigh the problem itself and the risk of that, versus the risk of the procedure you're doing to address the problem, versus the risk of an alternative procedure, whatever that might be.

This is what you're doing. There's no way around it. What you try to do in offering a solution that involves radiology is to avoid the very worst thing, which is wasted radiation, radiation exposure to no purpose, or radiation exposure that has to be repeated, because whatever it was, didn't get the answer you're looking for.

[0:51:10] MD: Which is what Caroline went through with the core Ð

[0:51:12] SS: Exactly, exactly. Which she already talked about. You definitely, whatever risk there is, you don't want to increase it by forcing there to be repeat studies, or lengthy studies because you're doing it wrong.

[0:51:31] CB: Again, in all the studies I watched, I always am reminded how important it is to do it right. Because you are, you're always exposing that patient to radiation. With a little one, sometimes you're exposing them to scary situations for a little one that's already had a lot of scary situations, or is going to have even more scary situations. If you can do whatever you can in this assessment, in particular, to make sure that you're gathering really good information to set a plan of care, so that you don't have to repeat it, or make it last longer than it needs to, anything that we can do as clinicians, we really should.

[0:52:15] MD: You touched on one of ErinÕs strengths. ErinÕs actually taken a bunch of advanced courses. What is Ð the trauma informed Ð I would butcher the course you took.

[0:52:27] EF: Trust-based relational intervention.

[0:52:29] MD: Yeah, that one.

[0:52:31] CB: Awesome.

[0:52:34] MD: SheÕs talked about it at length about how we need to be trauma informed within our clinical decision making.

[0:52:42] CB: Well, even I think for a lot of that, it's just the acknowledgement. Sometimes a child and a caregiver just needs acknowledgement that this is a thing that they Ð no parent wants to be in the radiology suite. That's not what they picture. That's not necessarily that was their ideal situation. Just having acknowledgement of that and being there with them and making them feel like that's not wrong for them for feeling that way can go a long way.

[0:53:14] MD: Wait. Dr. Steven, can you tell us how does it impact the poop?

[0:53:18] SS: Oh.

[0:53:19] EF: Oh, she's really Ð Yeah.

[0:53:21] MD: Because I get asked that question all the time.

[0:53:25] EF: We tell them that their poop may look white.

[0:53:27] SS: Oh, yeah.

[0:53:28] MD: Oh, God, we laugh through them.

[0:53:35] SS: So, look, if you were to just eat a mineral powder, just powdered barium sulfate, that would be very constipating. It might even reform itself into concretions, into like rocks in your intestine. That would be a bad thing, but that's not how these things are made. One of the ingredients that you will find in every barium sulfate product is an osmotic laxative. A laxative that will draw, or keep water in the bowel to keep the product in a suspension in a liquid form so that it can find its way to the other end and leave and not settle into concretions, or be constipating.

Every product, including all the Varibar products, have either Xylitol or Sorbitol, something in there to keep water in, so that the barium can stay in suspension as much as possible and find this way to the other end.

[0:54:33] MD: Excellent. I feel like, you'll probably have, waiting in the wing, some FAQs. What are the most frequently asked questions, aside from the color of poop do y'all get at your facility?

[0:54:46] CB: Yeah. Like I said, on our website, we have a little Contact Us button. We also sponsor a lot of conferences, so I get to talk to clinicians all day. It's actually my favorite part of my job is talking to clinicians. I have a lot of questions. How about I just softball them and pitch them up to you, Dr. Sireci? Sound good?

[0:55:06] SS: Okay.

[0:55:07] CB: Okay, perfect. I'm going to start with, on your website, sir, it says that there are pediatric indications for Varibar thin, Varibar nectar and Varibar thin honey, but it says six months and up for Varibar honey and Varibar pudding. Can you please explain that to me?

[0:55:27] SS: Well, that's viscosity based. The zero to six months also is a regulatory category. To distinguish an age group, that's probably the smallest distinction, that six-month period. When you're going to do an indication for a product, zero to six months is pretty standard. An imaging product is pretty standard as that the youngest and smallest range group. What you have to think about is the newborn part of that group. That's the distinctive part of that group, the real newborn, first month, second month.

We all know that in a newborn, you wouldn't give them pureed green beans, or something like that, so you really don't want to give things that are puree thick that are Varibar products, like honey and pudding. There, the indication is for the thin, the nectar and the thin honey as things that, particularly on the low end of that range, first month, second month of life is going to be appropriate for them. But if the child is getting on towards six-months-old, five, six-months-old, and they can have thicker things, youÕre licensed professionals, you get to make the final determination what's best for your patient. If you feel as best for your patient to use a honey, or pudding for something that's at that age range, you go ahead and do it.

These are recommendations. They rise out of a regulatory process that we have to follow, but it doesn't preclude you from using your clinical judgment. Just realize that that's there because we're really focused on that first two months of age with this age group.

[0:57:13] CB: Yeah. That's what I say to clinicians, basically, is that it's developmentally appropriate. Just like, you're not giving a brand-new baby pureed green beans, like you said. You're not going to give them Varibar pudding either. Another question we get all the time is, can Varibar be warmed up for baby swallow studies? Can you warm it up?

[0:57:38] SS: Well, the answer is, again, that's up to you. People do notice on the package insert that there's a storage recommendation, that is for room temperature, basically 15 to 30 degrees, whatever. But warming it up prior to use is not storage. Don't worry about that part of the PI. What the PI is telling you there is if you can put it on a shelf for X number of months or years, it should be at room temperature. When you get a product ready for use immediately before giving to the patient, you do what you have to do for the patient's comfort.

We've tested, for instance, warming the thin liquid to see if it changes anything, and it doesn't. Its viscosity remains basically the same, which is a very low viscosity equivalent to that of breast milk. It's really okay to warm it before giving it if that's what's going to make the child more comfortable.

[0:58:34] CB: Okay. Awesome. Then one more FAQ is, can Varibar be mixed with breast milk?

[0:58:42] MD: Oh, that's a good question.

[0:58:45] SS: That's a great one to end on. Yes. Okay.

[0:58:47] MD: When Erin and I are both CLCs, so we do breastfeeding as well. I mean, and I did breastfeeding. I mean, I lost two cup sizes doing it, but the children survived. We all survived. Continue.

[0:59:00] SS: Sure. There are two things to consider now. It depends on what you mean by being mixed with. If you're talking about thin liquid, we know that thin liquid comes as a powder and then you constitute it and the instructions say, constitute it with water. If you'd like to constitute it instead with breast milk as a replacement for water. I mean, that's off label, but again, that's up to you in your judgment as a clinician if you want to do that. Given that breast milk has a viscosity of about 4 centipois, and so does thin liquid, it doesn't seem that you would be changing Ð that's the units of thickness.

[0:59:44] MD: Okay. Erin and I are both looking at each other like, ÒWhat the heck is ÐÓ

[0:59:49] SS: ItÕll also say, milli-Pascal seconds, but poise. Based on poise is fluid mechanics.

[0:59:56] CB: This is how I explain it to clinicians.

[0:59:58] SS: DonÕt worry about it.

[1:00:01] CB: So, pounds. Yeah, pounds measures weight. Centipoise measures viscosity. That's a new word of the day. Centipoise.

[1:00:13] SS: Thickness, the resistance to flow, which is viscosity. Okay. This is fluid mechanics. Okay. What you see in the package insert when it talks about viscosities, it has this little initials called cP. That means centipoise. That's the units of thickness. Okay. Since breast milk has the same thickness as thin liquid, so what, right? It's not really going to change anything. However, if you are talking about, well, why don't I put in some breast milk into nectar, or thin honey, because it'll make it easier for the child to drink? Now you're changing it. Now it's no longer thin honey or nectar. It's something else homemade, and you don't know what it is you're testing anymore. You don't know the thickness of it. You don't know what it means. You've changed it.

I would just say that, and you've also diluted the radio density, the amount that it's going to block X-rays. Don't dilute things with breast milk that are pre-made, or don't take thin liquid, make it with water, and then dilute it with breast milk, because you're going to dilute its radio density and make it difficult for the radiologist and you to see what you're doing. It's going to change the viscosity and you're not going to know what it is you're testing anymore.

[1:01:39] MD: It's going to take me a day to process all of the information, and I don't even do the bloody swallow studies. Also, the total joy that y'all have for what you do that you can geek out to the level of those technical terms, I'm excited because we learned the word scurry yesterday, which is a group of squirrels, because they were eating the bird feeders and the eight-year-old wanted to know that. I mean, our word of the week was scurry. How do you say the centipoise?

[1:02:09] SS: Centipoise. It's named after the scientist Poiseauille? The French scientist, who came up with the laws of fluid mechanics.

[1:02:23] MD: I guarantee, my husband would know that.

[1:02:25] SS: Sure. Ask him. If he's an engineer, he knows better than me, but yeah.

[1:02:33] MD: Okay. I know people are going to have additional questions. How do they reach you? How do they field their questions to you? Or how do they follow y'all on Instagram, or what have you?

[1:02:47] SS: I like to add with that.

[1:02:51] CB: The easiest thing to tell them is they can reach out to me directly. I can give you my email address and put it in the show notes. Or, they can go to varibarmbs.com. Like I said before, there's a Contact Us button on there. They just click it and enter in questions. Those questions come directly immediately to me. I'm happy to answer them, or disseminate them.

[1:03:18] MD: Does Bracco have an Instagram, or social media presence, or a Twitter account?

[1:03:23] CB: No, we do not. We are on LinkedIn, but because it's a pharmaceutical company, there's no real social media presence.

[1:03:29] MD: Okay.

[1:03:30] CB: Yeah.

[1:03:30] EF: But you can see them at ASHA.

[1:03:34] CB: Yes. We will be at ASHA. We will have a booth there. We would love to meet as many clinicians as possible and answer all their questions. I will have my whole team there with me. We are happy to discuss with clinicians. We also bring Varibar with us, obviously. You're more than welcome to touch it, see it. You can see the differences and we can show you physically some of the properties that we've been talking about that are differences.

[1:04:03] MD: Can I put in the request that y'all please do a Willy Wonka tour to the facility giveaway at ASHA?

[1:04:12] EF: Michelle just wants to win it.

[1:04:13] CB: LetÕs see what we can do. I've only been with Bracco for six months. I don't know if I have Ð

[1:04:18] EF: SheÕs like, ÒMichelle, easy. Boom.Ó I think it's not, like you saying that this was built off of a need from clinician?

[1:04:27] CB: Absolutely.

[1:04:29] EF: It also helps clinicians should help clinicians feel empowered that they have a role in, and help clinicians feel empowered that if they want to do more research, or the reason for making things more standardized, this is all us working together more to create something that's giving better information, that's helping our patients, that's continuing to grow. Because like you said, this is still a fairly new part of our field. Yeah, go ahead.

[1:05:00] CB: Just wanted to throw out there, in-line with that is the Ð you might already know those, but the first, the very first standardized validated assessment tool for bottle fed babies is now public. It was just published. It's the baby BFS-S impairment profile.

[1:05:17] EF: I was just talking about that yesterday. I didn't know if it was officially published yet.

[1:05:22] CB: It is officially published. Dr. Bonnie Martin-Harris and Dr. Maureen Lefton-Greif actually gave us permission to share the PDF with you, so I can give that to you in the show notes.

[1:05:34] MD: Oh, my God.

[1:05:34] CB: Yeah, which was so kind of them. Wonderful. It's the training platform for it right now is being developed. You definitely want to stay tuned. It's so important. This is such an important move forward for swallow studies and bottle-fed babies. We are using and seeing more implementation of video fluoroscopic swallow study in children. Our approach hasnÕt kept quite up with what we know about swallow physiology. There are really super unique features in oral and pharyngeal dynamics in bottle-feeding babies. It really requires a lot of specialized training and observation analysis. I really feel like this tool is so huge for elevating the standard of care for babies.

[1:06:21] MD: This is going to fill a need.

[1:06:26] CB: Yes. Absolutely. Really, really exciting for the field. It's awesome.

[1:06:30] MD: Okay. My brain's going off in 14 different directions. If somebody listening, I'm choked up. I need to go get another cup of water. If somebody listening wants to Ð is inspired after y'all answering all the questions and mild humor jokes inserted, do you have a preferred scholarship, or nonprofit that folks can make a donation to, or tie that their time with, anything of that nature?

[1:06:57] CB: Yeah, definitely. For me, the Dysphagia Outreach Project is such an important resource right now. If your listeners are not familiar with it, you should go to the website.

[1:07:11] EF: Oh, yeah. We talk about it all the time.

[1:07:12] CB: Yeah. I'm sure you do.

[1:07:13] MD: WeÕve done podcast with DOP and did a [inaudible 1:07:16].

[1:07:16] CB: Beautiful. Yup. Yep. Full disclosure, I used to volunteer with them, but it was just Ð it's such a great organization. Also, the National Foundation of Swallowing Disorders is just a fantastic resource. Either one of those two are awesome.

[1:07:33] MD: Beautiful. We've done podcast with NFOSD as well. Yeah.

[1:07:37] CB: Yeah, they're fantastic.

[1:07:39] MD: Dr. Steven, do you have a scholarship, or organization that you would love to shout out? Maybe a big favorite ball team. I mean Ð

[1:07:48] EF: Oh, my gosh.

[1:07:51] SS: Listen, I fully endorse what Caroline said, particularly the National Foundation of Swallowing Disorders. For me, it's not a pediatric experience. It was experience with my elderly mother, who after several years of struggle, passed away suffering from dementia. I could see that the problems with eating was a big part of it. It's a big part of what happens to the elderly people. I know it's not your area. Your area is pediatrics. For me, just the dysphagia area in general is very important. It was very important in what I saw my mother's decline over a number of years. That's what's on my mind right now. I would just second that with what Caroline said.

[1:08:40] MD: Beautiful. Thank you. Folks, if you're not familiar with NFOSD, when you join, and it's nominal to join their organization. Or if you send a little love money their way, they actually fund new research to help improve the field of dysphagia across the life continuum. They have significant volunteer works. One Thursday, every month they have an adult dysphagia and caregiver support group. One Thursday every month, they have a pedes dysphagia and caregiver support group in DOP.

Again, go back and check our partnership with them that we did two summers ago, understanding dysphagia. There was a nine-part podcast mini-series and we've also had numerous volunteers from DOP on First Bite over the course of the last five years. Any donations that you give go directly to putting product in the hands of patients across the life continuum, including bottles, formula, thickener, blenders, you name it, they'll get it there. Also, they do have very active Facebook, Instagram accounts, so check those out. Erin, did I forget anything?

[1:09:53] EF: I donÕt think so.

[1:09:55] MD: Sweet. Okay. Dr. Steven and Caroline, thank you so much for coming on and putting up with all of my lame jokes today. I really need to finish writing these journals. I've gone punchy.

[1:10:06] SS: Good luck with that.

[1:10:08] CB: Thank you. Thank you, guys.

[1:10:10] MD: Thanks.

[END OF INTERVIEW]

[1:10:12] ANNOUNCER: Feeding Matters guides system-wide changes by uniting caregivers, professionals and community partners under the Pediatric Feeding Disorder Alliance. What is this alliance? The alliance is an open access collaborative community, focused on achieving strategic goals within three focus areas; education, advocacy and research.

Who is the Alliance? It's you. The Alliance is open to any person passionate about improving care for children with a pediatric feeding disorder. To date, a 187 professionals, caregivers and partners have joined the alliance. You can join today by visiting the Feeding Matters website at www.feedingmatters.org. Click on PFD Alliance tab and sign up today. Change is possible when we work together.

[1:11:04] MD: That's a wrap folks. Once again, thank you for listening to First Bite: Fed, Fun and Functional. I'm your humble, but yet, sassy host, Michelle Dawson, the All-Things PFDs SLP.

This podcast is part of a course offered for continuing education through speechtherapypd.com. Please check out the website if you'd like to learn more about CEU opportunities for this episode, as well as the ones that are archived. As always, remember, feed your mind, feed your soul, be kind and feed those babies.

[DISCLOSURE]

[1:11:51] MD: Hey, this is Michelle Dawson, and I need to update my disclosure statements. My non-financial disclosures. I actively volunteer with Feeding Matters, National Foundation of Swallowing Disorders, NFOSD, Dysphagia Outreach Project, DOP. I am a former treasurer with the Council of State Association Presidents, CSAP, a past president of the South Carolina Speech Language and Hearing Association, SCSHA, a current Board of Trustees member with the Communication Disorders Foundation of Virginia. I am a current member of ASHA, ASHA SIG13, SCSHA, the Speech-Language-Hearing Association of Virginia, SHAV, a member of the National Black Speech Language Hearing Association in NBASLH, and Dysphagia Research Society, DRS.

Additionally, I volunteer with ASHA as the topic chair for the Pediatric Feeding Disorder Planning Committee for the ASHA 2023 Convention in Boston, and I hope you make it out there.

My financial disclosures include receiving compensation for First Bite Podcast from speechtherapypd.com, as well as from additional webinars and for webinars associated with Understanding Dysphagia, which is also a podcast with speechtherapypd.com. I currently receive a salary from the University of South Carolina in my work as adjunct professor and student services coordinator, and I receive royalties from the sale of my book, Chasing the Swallow: Truth, Science and Hope for Pediatric Feeding and Swallowing Disorders, as well as compensation for the CEUs associated with it from speechtherapypd.com. Those are my current disclosure statements. Thanks, guys.

[1:13:49] EF: The views and opinions expressed in today's podcast do not reflect the organizations associated with the speakers and are their views and opinions solely.

[END]
FBP 256		Transcript

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