53: Swallow Studies Simplified with Ashley Stone, SLP

Say goodbye to the mystery that often surrounds swallow studies. As a parent or healthcare provider, you'll come away with a better understanding of this necessary, yet often misunderstood procedure. Tune in as we deep dive into this topic with our special guest, speech pathologist Ashley Stone.

We start off our conversation with telltale signs indicating that a child might be having difficulty swallowing - everything from persistent coughing to refusal to eat. We then walk you through the process of a modified barium swallow study and highlight the differences between hospital-based and private, outpatient clinics. Ashley's insights also guide us in creating a more comfortable environment for children undergoing these studies and the importance of a smooth transition time before eating.

Towards the end, we touch on some practical tips to improve the swallow study experience for both children and their families. We also discuss the controversy of repeat studies, the benefits of helping children feel at ease, and the need to be cognizant of the cumulative effects of radiation exposure. Wrapping up, we emphasize the power of advocacy, guiding you on the path to finding the right provider, asking the right questions, and connecting with others.

Feel free to reach out to Ashley with any questions or concerns:  ashley@diagnostex.us

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Transcript

Mary: 0:00

Welcome to the Speech Source Podcast. Today we have a special guest on. Her name is Ashley Stone and she is a speech pathologist that both Kim and I have had the privilege of working with with kiddos who have swallowing disorders and difficulty swallowing. Ashley is going to be our guest today to talk through swallow studies. If you're a parent, what can you expect if you are looking for a swallow study for your child, and how can you be your child's best advocate and know that you have choices for where to go when you have concerns about what your child needs? So, ashley, welcome. Thank you, and it's nice to be here. If a child comes in and has difficulty with the swallow, as SLPs we work with it, but we don't have X-ray vision. So how do we tell when a child is having difficulty? That's when we do a modified barium swallow study. Essentially it's a moving X-ray and what we're doing is just watching the kid eat and drink. So I tell parents I want you to bring food that they might enjoy. That's their favorite.

Mary: 1:17

As a parent with a child who suspects that their kid might be having trouble swallowing, what are those signs that you are looking for? What are those typical things that's going on at home, the most common ones that we'll hear from parents or physicians or their treating speech therapist. Maybe they're coughing or they're choking during eating and maybe it's just with liquids. We may hear they're like chronically congested. They never had pneumonia. They get their allergy pills, they're on reflex meds but they just kind of always have this congestion. That's there. Reflex is also a huge one that we'll see a lot. Sometimes in babies it'll be they've slowed down their eating. They're not taking as much as they were. Sometimes we'll see they're refusing to eat. Vomiting can be a sign if it's severe reflex In babies too. If they have watery eyes or they spike a fever after they've eaten, too can both be signs of aspiration.

Mary: 2:20

These are things that as a parent, they're tricky things to look out for, because most of the things you just described are normal to happen at certain periods. I mean, every kid's going to get congested, every kid's going to cough and it go down the wrong way at some point. But what you're saying is really when you're seeing this pattern of chronic congestion, chronic coughing, when they're feeding, that's when you should bring it up to your pediatrician. Correct, exactly. Then say you see all these things and you bring them up to your pediatrician. They say, yes, you know what. I'm a little concerned about that too.

Mary: 3:01

Let's go ahead and get a swallow study. Tell me what that looks like. What should a parent be prepared for? Because in my experience, a lot of times parents don't understand how major this study can be until they get pretty life-faltering results sometimes.

Mary: 3:25

Yeah, exactly when we receive an order for a swallow study from a physician, I will always call the families. When I make that phone call, I get a birth history, a medical history, but also I want to know a good feeding history. I want to know everything. What is their other developmental history look like? Because that all plays a role into feeding. But then I will also clearly explain. Here's what you should expect. We want you to arrive at this time. I will be prepared, I will have everything ready so that when you get here we can go ahead and start this study. I will block an hour for them. That is an hour to do the study, to do the teaching, the education. Wow, okay, that is not reflective of everyone's experience of swallow studies, correct, correct? This is a little more boutique experience, which is absolutely incredible. How does your continuity of care throughout the whole process affect the results that you get? How does that create a better experience for them Exactly?

Mary: 4:33

I really want to build a good report with these parents, because then they trust me and I trust them. Then they are more likely to ask more questions from me, because I want to know everything. I want them to be honest with me. I want to know is this going to work for your daily life? If not, let me try this. I'll always ask in this study is there something else that I didn't do that you want me to look at? Because I want to make sure that when they come, they got to see everything they wanted to see. We get in the study and maybe a kid's crying or we're trying to keep their attention. I may forget that mom really wanted me to try the spaghetti that they want to eat every Sunday. I want the mom to feel comfortable Like, oh, can you please try that spaghetti? If I haven't built a report with them, they may not feel comfortable to do that and I want them to. Then you can really ask.

Kim: 5:24

Ashley, how is your place of work? How does that look different and how would a family end up there versus a hospital?

Mary: 5:34

I work for Diagnostics. We are a private outpatient modified barium swallow study clinic. Just like at a hospital, you go there and get this swallow study done. We are the same thing just on a much smaller scale. Parents have the choice, so they can go to a large hospital or they can come to us. We currently don't have a wait list. We're able to get patients in pretty quickly, which is nice, especially if there's a huge concern for aspiration. We don't want them ending up in the hospital with pneumonia Because we're a smaller clinic. We don't have a large parking garage and registration and check-in and all of that. They're just. They're graded at the front door and I'm ready for them and we're ready to go. We don't have large medical records department that they have to contact in order to get a copy of their solo study. They want a copy. I can give that to them. That's pretty easy. Same with other providers. They can call me and I will happily fax it over to them, with permission from the parents, of course. And continuity of care. I mean, I am the only one doing them right now as hopefully, as we grow and grow, I'll need more. But I want to continue that continuity and anybody else that comes along as part of our team does the same thing. It has that personable experience with families that I feel like is lost and make sure they have the time and feel like they're heard.

Mary: 6:56

You mentioned that patients have a choice where they get a swallow study. I think that is not known. Everyone doesn't know that you can actually advocate for where you get a study done and that there's even options. Wait time is everything in this world and pediatrics especially. If a mom calls and says, hey, I think my kid's aspirating, my physician is sent over this order. What does your wait time look like? Because they might be feeding seven, eight, 10 times a day. If they're an infant, that's a big deal. It's a huge deal and we want to keep them out of the hospital and they can easily end up there if they are feeding seven times a day and aspirating each time.

Mary: 7:39

We can generally get kids in, sometimes same week, but for sure the next week, just depending on everybody's schedules. Obviously, if it's that big of a concern, they're gonna be flexible and will come whenever you have time. If it's urgent, we can get them in same week, if not next, for sure If you're a parent and you get that referral. That is going to be a four month out wait. You are able to advocate for your child to say, hey, what other options are there? In my area Is there a private clinic that I could get a referral to instead so that I get this study done for my child sooner? Absolutely, and that's going to be a huge part that parents need to play, unfortunately. So if they've never heard of a private clinic, they're not gonna know to ask. But you're right, it doesn't hurt to ask or for them to hop on Google or whatnot and just look to see if there are other options, because you do have a choice and I think that has forgotten a lot.

Kim: 8:43

Once you get into specialists it is easy just to go down the path that the place you're already at. But I have learned that just in the last few years that you do have options for different testing scans or, if you had to have an MRI, that you do have options, and I think being able to just let parents know that they do have choices is great to term dysphagia.

Mary: 9:10

Could you define that for us, cause I think for a lot of people that's a new term and it also can be called dysphagia, which I think my dad called it in a medical school in the 80s. Oh gosh, that combination of all is together Just something. Just doesn't do it for me. I'm there too. I know, mary, mary. Okay, so dysphagia, what is that and why should parents know this term? Well, we actually were just talking to a mom earlier today that said she didn't know that term until her child's fourth swallow study, which is crazy that nobody had ever even introduced that term, because in the medical field that's the term that we use. Dysphagia is just a dysfunction in your swallow, so something is going wrong, something is being disrupted and feeding. So when parents go for a swallow study, this is not some routine scan. It's a pretty big study and I think in my experience what parents haven't always been prepared for is the fact that these results that you get with a swallow study are not easy. There's not usually a quick surgical outcome that you're getting from this right. So the outcome is going to be how does the family change the way they're feeding a baby to be safe, ashley, can you talk through some of the ways that you can make feeding safer for families and what kind of results people are getting after this? Absolutely.

Mary: 10:51

So let's talk babies, because there's a lot of different ways we can alter their feeding to keep them safe so you can change their positioning. The typical positioning of feeding a baby is held in the arms. We can change positioning. We can feed them on their side and that gives them a little bit more time to coordinate their swallow and their breathing.

Mary: 11:11

To safely eat, we can use thickener and basically the best way to describe thickener is you take normal breast milk or formula and you add some powder to it and shake it up and it makes it thicker. That usually will give the babies more time to coordinate their swallow and breathing. When you make it thicker, it slows it down to give everything more time. So that's another way to help make them safe. We can also pace babies with a bottle, and that's where I give them a break. So that's another way we can keep them safe when they're drinking from a bottle. One of the things that parents do often at home prior to a swallow study just on their own, is they will go through all the different bottle systems. Dr Brown's.

Mary: 12:01

Coma Choma, they'll go through everything, we'll have a whole cabinet of bottles and nipples. Yes, is that something that you have seen to be effective in the swallow is to change up the system they're using or the nipple size. It can be with a nipple size, for sure. Changing the bottle gets tricky only because, like you just named, there's so many different bottle systems out there. I think within every bottle system there is some movement with the nipples and positioning to keep them safe. As a new parent, if you're starting from the beginning, is there a certain bottle system that you would recommend that generally works for most babies to keep them safe? I personally like Dr Brown's. I know it's been around for forever and there's a love-hate relationship with all the components and the parts. But I always tell families if you don't want to use all the components you don't have to. That is okay, but I like the number of different nipple sizes that they have. I think they work really well. Most babies respond pretty well. They also have the wide nipple, so a lot of times I'll see moms that are pretty much exclusively breastfeeding but do want to give a bottle every once in a while. We'll use that wider nipple to make it more similar to their breast.

Mary: 13:23

How has being a mom changed the way that you operate for your patients? That's a great question. I think since becoming a mom, it just has opened my eyes a little bit more to the chaos that happens at home and the unpredictability of what your daily life might look like after the studies. I want parents to be successful, right. Our number one goal is to keep their kids safe eating. So what does a daily life look like for you? I just try to think about my life and I don't have a kid with a swallow dysfunction and how crazy my life can be. So I can only imagine how throwing this extra kink into their daily life can feel. I just want it to feel and be as easy as possible.

Mary: 14:10

What makes swallow studies a little bit different than just your x-ray is the fact that you have to have varium. You have to have something that contrasts with their anatomy so that you can really see the path of what's going down. It's not like an x-ray where it's like, hey, they just have to sit still for a second, it's done. It is not like that with swallow studies, because they have to be an active participant. They have to be able to swallow to see whether it's going the right way or not. It's a very dynamic study. Yes, it's just eating, but, like you just said, it has to be some varium.

Mary: 14:49

Additionally, kids get in there and they're like what is all of this? There's all this equipment behind me and around me and we're in this smaller room and there's a radiologist over here. What is he doing over there? You're wearing heavy vests and collars and they're like whoa. Then you have there's a TV, there's a monitor behind the patient so that I can see what is happening. Then, inevitably, you'll have the really alert kids that are turning their head around to see what we're looking at. When we're doing a swallow study, in order to see the anatomy accurately, I need their head straight and looking forward. If you give them something to eat and then they turn their head and swallow, it distorts all the anatomy. That is a huge moving piece. We'll pull out toys and we'll pull out bubbles and some parents will pull out their phone and put on a show.

Mary: 15:42

It's hard for kids to participate with things like that, and especially when they're too little to understand the why they might have been poked and prodded in a healthcare setting before it seems familiar. It's like those kids especially. I remember in fees when I was scoping to do a different kind of swallow study. There is this one study, but it was the one that really didn't go as expected at all. It was because it was a kid who was combative, but for good reason. She had a heart condition, she had pulmonary conditions, she had all these things. She just walked in that room and she was like I am ready to go, bring it guys, I am going to take you. That is the experience sometimes that you're presented with, but it takes a provider who understands that and is able to cut through to the emotional level of the child to be able to calm them and let them know that they're trusted, they're respected, that this is going to be an experience that they're working with together so that you can ultimately get the results you want Exactly. That's a huge piece of it Within that hour that we allow.

Mary: 17:03

That gives me so much time to do some of those things, depending on the age of the kid or how tight they're clinging to mom and dad when they walk in. I can read them and maybe I'll stand back and I won't get too close to the kid, I'll say hi and whatnot, but I will always ask mom or dad or whoever it may be Do you think they're going to do better if you feed them or I feed them? Because I want to set the tone for something successful. I just stepped back and I let parents do and I will coach them.

Mary: 17:32

I've had a little baby before where she was not going to take that bottle. We probably tried for 10, 15 minutes and it was just a hard pass. Mom also breastfeed, so we let her have the room for five minutes and was like let's get her in a pattern and learn to trust us. Lo and behold, after she let her breastfeed for five minutes, we got in there and we did the bottle and then we had a successful study. Little things like that that I have the time to do, so that we all feel successful and proud and happy of the results we got, versus just, oh, they want to take a bottle, see you next time. Come back later. All those little things that I have to remind parents about too, when they're bottle fed too, is what time do they normally eat?

Kim: 18:16

That's when we want to see them.

Mary: 18:18

I mean little things like that absolutely make or break the study.

Mary: 18:23

And that's why you're going to be charged for that time, regardless of whether your child eats or not. It's so incredible that you have a little more concierge type experience for patients for swallow studies, because if you just run into a fluoro suite, you've been waiting for maybe an hour. All of a sudden you wheel them into this really freezing cold room with all the monitors and all the doctors. That's just the setting of how the hospital has to operate. But I read a study once that said the best predictor of how a child will eat is the five minutes leading up to that feeding. They're emotional state. So if you think about just your kid, how do they respond when you're just like let's go? There's a reason why, as parents, we give kids five minute warnings. Yes, absolutely, and we need that time to be able to process the transition that's going to happen. And with feeding too with bottle feedings or with kids and mealtimes like hey, come to the table in five minutes, go, wash your hands there's a reason for that period of calm and preparation to be able to eat effectively. But also it's going to be a reflection of their eating all day long, and so everything that you can do in the setting you have to make them comfortable and make it feel like a simulation of their home environment means you just got a way better end result than if you were guns blazing in and out to try to get that picture.

Mary: 20:06

You hit the nail on the head. I mean, I can't tell you how many times that happens in the hospital because, like you just said, that's how they have to operate, until they have to run and it's hard as a speech therapist to come in and do this wall study and you just see the defeat on the parents face and then I feel defeated and the kids crying and you're like what did I just do here? Like parents came and they waited and they did the study and we got nothing. And now everybody's leaving upset and maybe they drove an hour, maybe they we would have some families drive three hours just to come to a swallow study. And if you can't set them up for success, you just ruined their whole day and now they have to come back and do this again. Or you've halted their feeding therapy progress or you've kept them from weaning off the G tube or whatever it may be. It's not like you said, it's not just that moment in time, it's when they go home and for the next few months, what did you just change?

Kim: 21:00

And I would say you know we were talking a lot about the kid needing to be set up a certain way, and the environment. But parents too because that's really emotional for moms and dads and whoever's bringing them in, whether it's a baby or it's a child they're trying to figure out what's going on. There's obviously a problem Feeding is already such an emotional thing with your kids anyways and it's scary. And so being able to even have the parents in a place where they're calm and they're able to relax, we know that that affects their child, they can feel that, and so I think it's not just the kid, it's the whole family that you're wanting to give them the best experience possible to get what you need from that.

Mary: 21:51

Absolutely, and that's where the building that we're poor and calling the parents first is because then they walk in the door and I introduce myself I'm the one you spoke to on the phone and they're like oh yeah, I remember talking to you versus meeting everybody there for the first time, as well as, like you just said, being a little nervous, being anxious. Maybe they've been going through this journey for nine months and finally they got somebody to agree to this follow study and they are so nervous that, like Mary mentioned earlier, could be life altering for them. They may not be able to just take water out of the faucet and feed their kid anymore, and that's a harsh reality and you need parents in that mindset and you need them calm and understanding and comfortable, as they can be. So if you are in a position where you're a member of the team that are doing these follow studies or referring for them, or if they are in a little bit more rushed environment, is there something that you've put into place in your practice that you think might be able to transition to other settings so that more patients could have a better experience and outcome? Absolutely, when we get the order, we'll call the parents and we'll get them on the schedule. We will also send them an email with an intake form and kind of like a document I created on what to expect for your follow study. So it goes into what to bring and it could be anything from bottles and nipples and cups and whatnot, but also maybe a change of clothes, maybe bring some snacks for afterwards or formula for afterwards in case they're hungry. Bring their favorite toys, things like that, because I do know that in the hospital you are busy and you don't have time to pick up the phone and call every single patient you're seeing that day, because there could be a lot. So that's something that I think would be helpful in the big hospital systems, that when they just don't have the time but that's been really helpful just to cut down on some time too, once they arrive, because I've already got everything I need, they already kind of know what to expect and then we can just get started.

Mary: 23:56

Are there any little tips and tricks that you've found to be successful to calm those who are getting nervous, to encourage them that they are safe and to be able to eat a few bites? We have toys, we have stickers, we have bubbles. Sometimes you know they'll see me I think I mentioned that about. They'll see me put the laberian powder on their food. So sometimes I'll give them a bite without any and I will show it.

Mary: 24:20

I will hand that applesauce cup, put it right in front of them and take a spoon and let them have a couple of bites of applesauce first so that they gain some trust, and then I can turn around. Usually I'll sprinkle a little on the spoon, dip it in the applesauce, sprinkle a little bit, dip it in the applesauce and try to hide it as best as I can. I hate feeling like I'm tricking the kid, but you know you have to do whatever you need to do to gain some trust and make them feel comfortable. So those are a few things we do. I mentioned, you know, letting mom breastfeed if she needs to, just to calm down. I'll let parents take the kid in and out of the tumble form. Sometimes that can backfire because you know if they're super upset they'll take them out of their chair, try to comfort them and then that kid is not leaving mom or dad's side.

Kim: 25:06

Do you ever have them sit on a parent's lap? I know that's not ideal because you're dealing with radiation, but do you ever?

Mary: 25:14

have go there? I get that question a lot and unfortunately we can't. And it's not just the radiation exposure, but if they're sitting on the parent's lap now, you're getting all the anatomy from whatever parent is right there. Unfortunately, that's not something they can do in a solid study. It seems like the research now is really leading towards the cumulative effects of radiation on the body, and then it's not truly just one moment in time study, but we really need to be looking at have they also had XYZ studies? And then how is that adding up over the course of their lifespan? So let's take a moment and talk about repeat studies, because that's a really big deal. So you have a kid in front of you and you've just given them the result that, okay, you need to be on an altered diet, whatever it may be. What's the plan? And then, at what point should you come back and reassess what's happening with their swallow? Great question Following a swallow study if they're not already in therapy?

Mary: 26:23

They have some recommendations for therapy places. Again, parents have a choice. You can go wherever you want. Now you'll have to call that physician and get an order sent to the place that you do want to go, but you can. So make sure they're set up there. If they are not set up, I will also call the physician's office. Of course it's in my report, but I also want to call and put that in right away so they can get started.

Mary: 26:46

In the report it won't just list whether they've aspirated, meaning the food or liquid went into the airway, but it's also going to mention the dysfunction and the deficits. So why did they aspirate? There's so many structures that have to move at the right time for you to swallow safely. As one of those structures not moving enough, not moving at all is the timing just off. It's really important for those speech therapists to know the why behind it so they can treat the why. So many therapists will just know they're aspirating and they're on thickener. But what do you do with that? Then, as far as follow-up swallow studies go, there's a huge generic comeback in three to six months. I hate that. Again, I have a problem with that. If you're a two-year-old and you started having swallow studies in the NICU, how many swallow studies will you've had by the time year two? Right, we just talked about how much radiation are they now exposed to and time spent and all these other things, and what changes are we making from swallow study to swallow studies? So I am more on the side of hey, let's get some good therapy. And let's say they're having problems chewing and then swallowing. I want that speech therapist to work on their chewing. And when their chewing has been mastered, then let's come back and look at it. Same thing with transitioning from a bottle to a cup. Okay, so we're not doing well on the bottle, let's practice some cup drinking. And when they've mastered that skill, why don't you come back and let's look? Because there's a big difference in the swallowing pattern from a bottle to a cup. So maybe they weren't good at a bottle, but suddenly you give them a straw and they look perfect. It's more skill-based than time.

Mary: 28:33

Status change I mean, you said it before. That's really the mark of when you should get another swallow study is when you've had a status change. Maybe they've had a hospitalization or pneumonia. You're on the oh gosh. We might have had a status change for the worse. Or a status change like you said, saying we're drinking from a straw now and a cup, and now we're eating different foods. Or hey, you know how the tongue couldn't move very well. Well, it can move better now. So let's see.

Mary: 29:01

And so to go for a swallow study to have a repeat? We would want to go because we expect the results to be different. Exactly, you hit the oh my gosh, yes, oh my gosh. I that's how I'd say it to parents. I'm like, why would I want you to come back in three months if we're still drinking from a bottle in this nipple? We haven't transitioned, we're not going to see anything different unless, like you said, there's a change in status. And unfortunately, you know there are a lot of families that are having a hard time getting good, consistent therapy. So sometimes it is taking them a month or two months to get a good therapist and I don't want to see them in three months if they've only had one month of good therapy. But you know parents are doing what they are told. So even though they haven't gotten therapy the first two months, they still assume to come back in a month. And that's that's not their fault. Diagnostics has been in existence for 20 years. You know this is a much needed study to keep patients safe 20 years.

Mary: 30:01

So I know you haven't worked with them for 20 years Ashley but that has the incidence of swallow studies increased Just the need for them. Because I think about the last 20 years with infants, I mean, think about the number of micro-premies of 27-weekers born now and 32 weeks, and we know that the likelihood of having swallowing difficulties in preterm infants is so much greater. Have you guys been seeing that? Absolutely. And you mentioned micro-premies. I mean when I started in the NICU in 2014,. You know we saw a couple 25-weekers here and there, but since then I mean I'll say 23-weekers now. So the medical advanced. It's amazing. And yes, they're not in the womb. These babies are missing out on multiple weeks of practicing their swallow. So babies are swallowing the amniotic fluid when they're in the womb and when they come out that early now they're not swallowing anything. We're not giving them a bottle at 23 weeks, right. So they're missing out on and they've had all this trauma to their mouth when they're born that early. They're intubated. They may have a feeding tube down their throat, they've got tape on their face, they've got oxygen. They are hit with all this trauma to their face and that ultimately can lead to oral aversion. And then we have other problems besides just the swallowing problem. So, yes, we have seen a huge uptick in that and I think just the knowledge and spreading awareness to other families and other professionals and making it easier to alter diets and making it more acceptable and helping families navigate it a lot better than we did 20 years ago. It's huge. Even adults, I mean, they can have whatever adult beverage they want and thicken it, you know, and that's neat for them to still feel like they can have a life like their friends and still be able to enjoy those things. So yeah, it's changed a lot in 20 years for the better. That's incredible.

Mary: 32:09

Well, there was this article in the Asha leader that came out.

Mary: 32:13

It just came to my house yesterday, but it was this article about swallowing difficulties in SNFs so skilled nursing facilities and it was a really interesting article.

Mary: 32:24

It was obviously in a publication that's geared towards speech pathologists who are working with adults that you would see difficult to swallowing, but it was advocating for speech pathologists to be able to go to their facility and say, hey, we need better access to swallow studies for adult patients and we need better options and the outcomes. They listed some statistics that I'd never seen before. They said that, in addition to making a world of difference for that adult to be able to drink their coffee safely versus saying, nope, can't have your coffee anymore, dude, sorry that it is costing facilities a tremendous amount of money every year. This article was saying that if you were on an altered diet, it would cost a nursing facility anywhere from $5,000 to $10,000 more per patient per year On those altered diets. And then if you were in PO, so if you couldn't eat anything by mouth, it was costing the facility anywhere up to like $50,000 per year per patient, oh my God.

Mary: 33:39

And so the thing that you do is on that diet for all the tube feeds, for all the things that you're thinking about. That is just basically saying it is not cheaper, easier, safer any of these things to be on tube feeds or to have altered diets, and that we should have better access to swallow studies, like you guys, right, and so you know you would see what is going on and then have a proactive role and what's the outcome. How do we get them off of this? Right, and that goes back to being a part of that collaborative team and making sure that everybody is aware that this is an option, it is a good option, and then following up post swallow study with the trading speech therapist too, to diagnostics and go out to the nursing facilities and whatnot.

Mary: 34:33

We have the adult speech therapists do that, but I have heard they are seeing a lot of turnover in speech therapists at those places too. They're just hiring a lot of PRN speech therapists that work here and here and here and here, versus pre-COVID just having one speech therapist or two speech therapists that stay at that facility. So that's a working piece, too that I know they're trying to navigate is forming those relationships with PRN speech therapists that you see now but I don't know if I'll see them again next time or whatever it may be. But that goes back to that team approach too. It's not just therapist to therapist, it's the physician and to the families and everybody to advocate for better quality of life for them, definitely Well. And I think about the application to pediatrics.

Mary: 35:21

If it costs that much for a facility to take care of an adult, or an adult who's having swelling difficulties. There's no facility to take care of an infant or a young child. That is that weight. The financial burden, the medical burden, everything falls solely on one or two parents' shoulders, Absolutely.

Kim: 35:44

Crazy.

Mary: 35:45

It is. And then you deal with the difficulties of insurance and approving this and approving that and you get families that are just exhausted and I can't imagine what it feels like as a parent to get a denial from this and feel like you have to be the one advocating for them and nobody else will. You have a pediatrician, you have a cardiologist, you might have a pulmonologist, you maybe you have a genetic specialist. You have all these people that are caring for your kid. But again, it's empowering parents to know they have a choice and they have a voice and they can improve their child's quality of life just by asking some questions. They have this huge burden of care, being that advocate for them. That's hard. Well, ashley, this has been phenomenal to be able to talk with you and pick your brain on swallow studies and get an inside view into what this looks like for families.

Mary: 36:46

I want to leave with a really actionable charge for parents and providers. Can you leave us with some kind of encouragement or tips that you have on how to be a good advocate for your patients or your children? I would start with the provider you're most comfortable with or have the best rapport. So, whether that be a therapist or a nurse or a dietician or a physician whoever you feel the most comfortable with. When you go to appointments, start asking questions or, if you've read an article, maybe mention it and see what they think. I think we've all been in contact with therapists or doctors that don't make you feel welcome and that's hard to ask questions to, or I don't want them feeling like I'm second guessing their opinion. I'm just trying to be a more informed parent. So I would start with that.

Mary: 37:44

Social media has become such a huge thing. There's a Facebook group for everything. I guarantee you you can find a Facebook group based on your kid's dysfunction. Obviously, don't take their medical advice, but it can put you in touch with other parents that are going through what you are going through. If parents are in the Dallas-Fort Worth Metroplex or they would like to get a study through diagnostics and with you, ashley, what is the best way to go about that?

Mary: 38:11

You can always email me. My email is Ashley A-S-H-L-E-Y. At diagnostics, that's D-I-A-G-N-O-S-T-E-X dot U-S. You can email me with any questions. If your physician's ready for an order, you're ready for an order. They can fax it over to our office and then we can get the ball rolling there.

Kim: 38:37

Ashley, we'll also put all of that contact info in our podcast notes and phone numbers, so if anyone has any questions or interests, you'll all be right there.