Virtual nourishment: Paediatric feeding disorder management with telepractice amidst COVID-19: An allied health perspective

Abstract

Purpose

The rapid adoption of telepractice services by health professionals was necessary to maintain service continuity for children with paediatric feeding disorders during the COVID-19 pandemic, during periods where in-person therapy was restricted. The aim of this study was to explore clinical perspectives and reflections on the use of telepractice for managing paediatric feeding disorders during the pandemic.

Method

A post-positivist qualitative approach using thematic analysis was adopted. This study seeks to understand participants’ experiences and thoughts from allied health professionals from speech-language pathology, occupational therapy, and dietetics working with paediatric feeding in Western Australia. All participants delivered at least 10 telepractice sessions to children from birth to 12 years with a paediatric feeding disorder. Braun and Clarke’s six-step thematic analysis process was used to analyse the data inductively.

Result

Eleven allied health professionals representing eight clinical settings in Western Australia, including speech-language pathology, occupational therapy, and dietetics, working with paediatric feeding were recruited. The results revealed four themes: families becoming the catalyst of change, clinician comfort over confidence, insights into authentic mealtimes, and the paradox of choice.

Conclusion

This study highlighted the need to build clinicians’ confidence and competence, and the provision of service guidelines and training. Although many clinicians had positive experiences with telepractice, most returned to in-person delivery once COVID-19 restrictions were lifted, emphasising the importance of comfort in service delivery selection. We recognise that the findings of this study are constrained by the fact that it was conducted in a single geographical region and utilised a small qualitative sample. While telepractice was successful in managing paediatric feeding disorders, further development and implementation of telepractice guidelines are needed for telepractice to be a viable service delivery option for families and children with feeding disorders.

Keywords:

• paediatric feeding disorder
• telehealth
• COVID-19
• allied health
• multidisciplinary
• swallowing

Introduction

Paediatric feeding disorder (PFD) is a universal term to describe infants and children with acute or chronic feeding and swallowing difficulties manifested by nutritional, medical, feeding, and/or psychosocial dysfunction (Goday et al., 2019). The prevalence of PFD is between 2–25% of typically developing children and 80% of children with developmental disorders (Benjasuwantep et al., 2013). PFD can negatively impact nutrition, physical health, cognitive development, social participation, and parent-child relationships (Malandraki et al., 2014). Consequently, timely and accurate assessment, diagnosis, and management of paediatric feeding disorders are essential to minimise patient risk, limit hospitalisations, and optimise the quality of patient care.

The evidence to support telepractice as an effective alternative to in-person service delivery for the provision of speech-language pathology services has grown over the past decade (Bridgman, et al., 2016; Burns et al., 2019; Grogan-Johnson et al., 2013; Raatz et al., 2021b; Molini-Avejonas et al., 2015). Studies have indicated that an effective therapeutic relationship can be established within a telepractice environment, with a high level of satisfaction reported by both patients and caregivers (Kelly et al., 2020; Kiger & Varpio, 2020).

The COVID-19 global pandemic placed significant restrictions on in-person service delivery with many service providers required to shift to telepractice. The rapid rate of this adoption was evident in one Australian tertiary hospital that showed a 2255% increase in telepractice over a six-week period in 2020 (Schulz et al., 2022). The rapid adoption of telepractice presented a challenge given the historically low level of uptake throughout Australia and across the globe (Kruse et al., 2018). This limited use of telepractice was particularly evident across both paediatric and adult feeding disorders (Cassel, 2016; Theodoros, 2012).

To ensure holistic care of children with PFD, a diverse team of health professionals collaborated to ensure comprehensive assessment and management, including speech-language pathologists, occupational therapists, and dietitians. A systematic review of telepractice was conducted with occupational therapists, which found it to be a user-friendly delivery model for the provision of services; however, only one study in the review focused on mealtime management in children with autism spectrum disorder (Hung & Fong, 2019). Similarly, a survey of Australian speech-language pathologists reported less than 5% used telepractice to manage paediatric dysphagia (Hill & Miller, 2012). More recently, 20% (17/84) Australian speech-language pathologists surveyed reported experience with the provision of telepractice with paediatric feeding, mostly in the preceding year (Raatz et al., 2020). While successful outcomes were achieved, including improved access for rural and remote clients, significant concerns were reported regarding safety, efficiency, and equitable access to technology in paediatric feeding (Raatz et al., 2020). During the COVID-19 pandemic, speech-language pathologists expressed heightened concerns regarding the safety of conducting feeding and swallowing assessments, particularly in relation to airborne particles. An Irish investigation by Rouse and Regan (2021) delved into the safety and psychological consequences associated with delivering in-person services. Their research revealed that up to 60% of surveyed speech-language pathologists experienced conditions such as depression, anxiety, stress, and post-traumatic stress disorder. Additionally, three participants expressed concerns about the conflicting guidance provided by their professional association and their employers’ policies and procedures regarding aerosol generating procedures (AGP; Rouse & Regan, 2021). AGPs are procedures such as swallowing assessment and treatment that can produce airborne particles, such as saliva or respiratory secretions, potentially containing infectious agents. In speech-language pathology and swallowing management, AGPs are crucial to consider because they can pose a risk of spreading respiratory infections, especially in patients with dysphagia or swallowing difficulties who may have difficulty controlling their oral secretions (Hung & Fong, 2019). While no studies were found on paediatric feeding from a dietetic perspective, the Dietitians Association of Australia’s position statement advises that telepractice consultations are comparable to in-person consultations for weight management and chronic disease management (Kelly et al., 2020).

Concerns regarding variable access to technology, difficulty establishing rapport, and uncertainty about treatment effectiveness were reported by speech-language pathologists and occupational therapists with the use of telepractice for feeding and swallowing difficulties in both paediatric and adult populations (Hines et al., 2019; Swales, et al., 2020). This current study aimed to investigate the perspectives of multidisciplinary allied health professionals regarding the use of telepractice for children with paediatric feeding disorders. The objective was to gain a more comprehensive understanding of the factors that either support or hinder the adoption of telepractice in this context.

Method

Design

A qualitative post-positivist approach using inductive thematic analysis was adopted to understand participants’ experiences and thoughts (Ryan, 2006). Institutional ethical approval was obtained before commencing data collection.

Setting and participants

Allied health professionals from speech-language pathology, occupational therapy, and dietetics working with PFD in Western Australia were recruited from July to December 2020. Participants included practicing clinicians who had delivered at least 10 sessions via telepractice to children from birth to 12 years with PFD over the previous 4 months. Convenience sampling was used for participants to be selected based on their willingness and availability to participate. A recruitment flyer was posted on allied health professional social media groups within Western Australia. Participants registered an expression of interest by email. Interested participants were provided with an information sheet and returned a signed consent form to participate.

Data collection

Interviews were selected for this exploratory study as they enable a broad understanding of the opinions, motivations, interests, and perspectives of the target population (Jain, 2021). Each interview included in-depth, clarification, confirmatory, and reflective questions (Pessoa et al., 2019). Interviews were conducted via videoconferencing on a mutually accessible platform (Zoom, Microsoft Teams) or by telephone by all three female authors (SS, MB, and DI). All interviewers are speech-language pathologists, two have doctoral qualifications, and all have more than 20 years of experience, including interviewing experience. Prior to recording, the interviewers spent time building rapport with participants. The participants were aware of the aims and objectives from the participant information sheet. Two of the interviewers had clinical experiences with telepractice before and during COVID-19 with children with paediatric feeding disorders. To avoid any potential bias, participants who had a pre-existing relationship with an interviewer were assigned to a different interviewer.

All interviews were audio and/or video recorded. A semi-structured interview guide was used (Appendix A) to explore a range of issues, including participants’ perspectives and reflections on telepractice for paediatric feeding. The guide was pilot tested with three clinicians and revisions were made based on their feedback. After the interviews were completed, participants were provided with a copy of the transcribed sample and given the opportunity to verify and edit the records.

Data analysis

The methodological orientation that underpinned the study was inductive thematic analysis, a qualitative research approach to identify patterns, themes, and categories in the data through a process of iterative and systematic coding. The analysis adhered to Braun and Clarke’s (2006) six-step process (Table I). The recorded interviews were transcribed verbatim, de-identified, and checked for accuracy by two independent reviewers. The same three members of the research team (SS, MB, and DI) conducted data analyses. To minimise potential confirmation, observer, and researcher biases, a systematic approach to data coding and analysis was implemented, and ongoing critical self-reflection was implemented. The team familiarised themselves with all transcripts and then conducted line-by-line coding to identify initial themes and patterns. The transcriptions, codes, and subthemes were discussed by the research team, who organised and refined these themes into higher-level themes. The coding process involved identifying and labelling meaningful patterns and themes in the data, using an inductive approach. Discrepancies in analyses between researchers were discussed collectively until a consensus was reached. Recruitment ceased when data saturation was reached, once information was repeated by participants and consistent themes were generated in the dataset. The study was reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ; Tong et al., 2007).

Table I. Braun and Clarke’s (2006) six-step process for thematic analysis.

Phase	Procedure
1. Familiarising self with data	Transcribe data; read and re-read, noting initial code
2. Generating initial codes	Systematic coding of interesting data across the dataset
3. Searching for themes	Collation of codes in preliminary themes
4. Reviewing themes	Check themes across the full dataset; generate a thematic map
5. Defining and naming themes	Refine themes
6. Producing report	Analyse appropriate data extracts; discuss analysis about the research question/literature; write the report

Result

A total of 11 interviews were conducted, which lasted between 21 and 51 minutes (M = 31 minutes). Five speech-language pathologists, three occupational therapists, and three dietitians were interviewed virtually from their clinical setting or home. All participants were female, and no one else was present besides the participants and researchers. No repeat interviews were carried out. Demographic information regarding the participants’ workplaces and experiences with telepractice was collected during the interviews and is summarised in Table II.

Table II. Participant telepractice use pre-coronavirus disease (COVID-19), during COVID-19 restrictions and post-COVID-19 restrictions.

Participant	Practice setting/s	Pre-COVID-19	During COVID-19 restrictions	Post-COVID-19 restrictions
100 (SLP)	Private.	∼Five families.	10 families, 16 occasions of service.	11 families (six rural and remote, five newborns unable to attend clinic).
101 (SLP)	Private.	Offered as an option but not provided to any families.	20 families, some twice/week.	Continue with telepractice at least once a fortnight.
102 (OT)	Outreach services to small rural towns and a clinic in a major regional centre.	Quite a bit.	A handful of telepractice sessions per day, approximately 40% for feeding issues.	Resumed in-person for most clients. Use telepractice for regional clients and very shy children. Conduct phone reviews between in-person appointments.
104 (SLP)	Private.	No experience.	80% of the caseload (70 children).	“Quite a few” children.
105 (DT)	Regional town.	More than 50 clients.	Face-to-face was permitted for high-priority clients only. All others were seen via telepractice/telephone.	In-person where possible. Telepractice with 10 to 20 clients (∼two clients per week).
106 (SLP)	Metropolitan children’s hospital.	Some phone reviews. Rarely telepractice.	Six to seven children per week over 2 months.	Continued with some clients. Complex children at high risk of aspiration seen in person.
107 (DT)	Private and public (community health).	Few clients.	Four families.	Half of the clients.
108 (SLP)	Not for profit and private.	No experience.	Three clients every week.	Most in person, only telepractice with one client (not for feeding).
109 (OT)	Private.	No experience.	All appointments.	Rural Western Australia and interstate clients.
110 (DT)	Metropolitan hospital.	∼10 patients.	Three to four patients for 3 days/week.	Once or twice a month.
111 (OT)	Metropolitan children’s hospital (outpatients).	Monthly telehealth for clients in research study and a couple of times per month in the year preceding COVID-19.	At least twice a week.	At least twice per week.

Note. SLP = speech-language pathologist; OT = occupational therapist; DT = dietitian.

Analysis of the interview data elicited four themes (Figure 1).

Figure 1. Key themes from allied health perspectives on telepractice for paediatric feeding disorders.

The four themes are: (a) families becoming the catalyst of change, (b) clinician comfort over confidence, (c) insight into authentic mealtimes, and (d) paradox of choice. The coding tree and indicative quotes to elucidate each theme are outlined in Table III and discussed further.

Table III. Coding tree and indicative quotes for themes and subthemes to elucidate each theme about participant’s telepractice use.

Theme	Subthemes	Indicative quotes
Families become the catalyst of change	Forced into coaching	“A lot of us have noticed because you can’t jump in and model, can’t rely on showing and do it yourself, it really pushes me to coach and upskill parents which I think is a fantastic thing, but it has certainly been challenging” (101) “It relies on you to be really good at coaching parents, and it is a different way of working” – therefore training required (111)
	Empowered families	“Giving families definitely more control and then being that catalyst of change to be a lot more empowering as opposed to me sitting there doing the direct feeding therapy” (104)
	Accelerated progress	“I was able to see gains a lot quicker from that mode of service delivery. And I think also from the parent coaching as well” (104)
Comfort over confidence	Fear of the unknown	“I was a bit terrified at the start” (104) “At the beginning, I was absolutely overwhelmed as to how I was going to be able to you know, support these clients with their oral trials … I just thought it was going to be an absolute disaster” (108)
	Just do it	“I think it’s just doing it, and getting in there and realising it that is something you can use” (105) “I think COVID gave everyone the push to start using it and become familiar with it, and then just continue on using it … We just never sat down to learn how to use the system” (111)
	Positive experience	“I really enjoyed it and I didn’t think I would … I feel a lot more comfortable with that now” (101) “It certainly has a really useful tool in terms of assessing, maintaining rapport even … some families actually enjoyed just getting on, having a chat, touching base with how things were going” (102)
	Back to face-to-face	“98% of my caseload is back to face-to-face sessions but I’ve still got … three consistent families that are still wanting to access telehealth” (104) “Our preference is obviously face-to-face where possible” (105) “It’s really bizarre how it’s just kind of going back to pre-COVID” (108)
Insights into authentic mealtimes	See more than before	“It’s been wonderful for getting a snapshot of what the child’s mealtime is like in the natural environment and that’s been the best part about it I think. Being able to watch them in their home, in the setup/positioning they have at home and to see what their interaction with caregivers is like without me being typically present. I think that’s really fantastic” (101) “The other family members being present, all of that. So, I think from that perspective, I find it helpful. We do a lot more in terms of just looking at mealtime setup, and mealtime environment. We can see where the family sit, we can see what it looks like, and we can fit it in around a time that is actually going to be a mealtime or a feeding time versus we just slot it in when it fits” (111) “It’s good to be able to see the family setup for eating meals. Where they eat, what chairs they are using, what cutlery they’re using, what food they’re providing. When mums are trying to recall … what they’re feeding the child, I don’t find particularly reliable. And it’s quite different when you see them actually providing food and how they provide it is quite different from what they describe and then how I interpret what they’re described to me” (110)
	Family-centred practice	“It’s about using stuff the families had access to or were closer to what they would have in a typical diet” (101) “Seeing what was in the kitchen and what we could use because that dictated what we could actually do in our session and that gave me a lot more insight into actually practically what is going to be the most functional things that we can work on. And the most practical for families given the equipment, the foods, the environment that they have” (104)
	Performed better at home	Some children “feeling a lot more regulated because they’re in their nice safe space at home” “So things like foods didn’t seem as challenging, because yeah, nothing else is changing in their day” (104) “At home, kids are more relaxed” “kids don’t even notice you’re there” (102)
Paradox of choice	Easier at home	“Really helpful for the population that we see, because coming into the hospital is really challenging … coming in and spending all that time in a car, to an unfamiliar environment, and then trying to replicate a feeding session” (111) “Some of my families weren’t up for treatment while they had several children at home and they had, you know they were not working, and they were just going berserk (102)
	Good for education and review	“Quite often it was obviously really hard for me to demonstrate strategies with mom over the, over Telehealth. So a lot of the time I was sending them YouTube videos and stuff of food play. Or trying to model that, talk about food through Telehealth while they were eating and trialling that sort of thing” (102)
	Clinician fatigue	“I don’t think we are necessarily designed to sit in front of the screen all day … By the end of the day after seeing five kids in a row on a screen, I was exhausted. It was hard work” (109)
	Not all clients	“You know, the research tells us that we can’t, you know, properly gauge every single aspect of an oral motor exam. There are aspects where we can and we can use, you know, camera angles and things like that to really support us. But there are some aspects; I can’t palpate a swallow. I can’t listen to breathing. Um, those types of things really did impact whether I would, suggest, a telehealth session in place of a direct face-to-face session” (104) “Obviously … particularly for the speech pathologist, with the swallowing side of things. There’s only so much you can do through the camera with a swallowing assessment” (102)

Families becoming the catalyst of change

Clinicians reported that they were thrust into using a coaching model of service delivery to provide services for paediatric feeding using telepractice. This coaching approach contrasted with their usual practice of being hands on with the children during the assessment and therapy process. Clinicians who had previous experience in coaching were able to transfer coaching skills to telepractice delivery: “it [telepractice] relies on you to be really good at coaching parents, and it is a different way of working” (111). However, other clinicians with little experience with coaching had to quickly develop skills to be able to provide an effective service over telepractice, highlighting the need for formal training in coaching: “a lot of us have noticed because you can’t jump in and model, can’t rely on showing and do it yourself, it really pushes me to coach and upskill parents which I think is a fantastic thing, but it has certainly been challenging” (101).

Overall, clinicians found that using a coaching approach resulted in families taking a more active role in therapy, with intervention strategies tailored to the needs and context of the family, resulting in the carryover and implementation of strategies at home. Families were reported to be more engaged with services, resulting in faster gains towards therapy goals and as such were the key catalyst of change: “giving families definitely more control and then being that catalyst of change to be a lot more empowering, as opposed to me sitting there doing the direct feeding therapy” (104).

Comfort over confidence

Several clinicians described themselves as lacking confidence, with many expressing apprehension—fear of the unknown—with telepractice for children with paediatric feeding disorder before the global pandemic: “I was a bit terrified at the start” (104). “At the beginning, I was absolutely overwhelmed as to how I was going to be able to you know, support these clients with their oral trials … I just thought it was going to be an absolute disaster” (108). As a result of being forced to use telepractice, through a process of trial and error, the clinician’s confidence increased: “I think it’s just doing it, and getting in there and realising it, that is something you can use” (105) and “I really enjoyed it and I didn’t think I would … I feel a lot more comfortable with that now” (101).

Many clinicians reported a positive experience for themselves and their patients, and indicated a desire to continue telepractice as a service delivery option in the future:

I think it provides some really great flexibility to my caseload. Also, you know in terms of efficiency of the day reducing travel components, access to families who you know live 30 minutes away. You know you can swap it out for a telehealth session … It’s given families, in particular, a lot more choice and control over how they want services to look. (104)

Despite these positive experiences, most paediatric feeding services returned to in-person sessions once restrictions were lifted (see Table II), suggesting that parental preferences in addition to clinician’s comfort were important factors in the selection of service delivery mode: “98% of my caseload is back to face-to-face sessions but I’ve still got … three consistent families that are still wanting to access telehealth” (104) and “our preference is obviously face-to-face where possible” (105).

Insights into authentic mealtimes

Clinicians highlighted the benefits of being able to see families in their natural environment, including seeing the physical setup of a feeding session and interactions between family members in the home environment:

It’s been wonderful for getting a snapshot of what the child’s mealtime is like in the natural environment and that’s been the best part about it [telepractice] I think. Being able to watch them in their home, in the setup/positioning they have at home and to see what their interaction with caregivers is like without me being typically present (101).

Working in the natural environment through telepractice also provided clinicians with the opportunity to tailor intervention strategies to best suit the family’s mealtime routine and resources, including food and feeding equipment, within the home environment: “good to see the family setup for eating meals … what chairs they’re using, what cutlery they’re using, what food they’re providing” (110). Several clinicians stated that some children were more comfortable at home than in the clinic/hospital and thus were more engaged, which provided a realistic perspective on family dynamics during mealtimes.

In a clinical setting … it’s also controlled and suddenly you see the house in chaos and there’s no control …. you’ve got siblings running around in the background, and I think that that has been both beneficial and challenging … I've been able to visually see what our families are confronted with every single day, day in and day out, particularly in an isolating situation where your children are stuck at home with you. Also, it’s not just a baby, but I have a whole family behind me that I'm working with at the same time, so. Um, that was probably the most challenging yet beneficial (100).

Paradox of choice

Telepractice was deemed a good option for many patients, but not all. The purpose (assessment or therapy) and discipline (speech-language pathology, occupational therapy, dietetics, or mixed) were reported to influence decisions over the suitability of the patient for telepractice. Clinicians from occupational therapy and dietetics reported they could conduct a comprehensive assessment of clients, whereas speech-language pathologists reported limitations with the assessment of paediatric feeding through telepractice as seen in the following quotes: “would never do an initial assessment via telehealth, we would always do an initial via face-to-face, so I think probably that more physical aspect of the assessment we would look at prior” (111) and “I definitely wouldn’t feel confident doing a new dysphagia assessment for that type of service” (101).

Concerns were also reported regarding the delivery of therapy online, such as conducting an oral examination, trialling viscosity changes for liquids, and trialling new teats for bottle-fed infants:

It was just the modification of a thickened fluid that they couldn’t access easily and the demonstration of thickening fluids. Often in the clinic, it’s a lot easier to demonstrate all of that to them” (100) and: “the research tells us that we can’t, you know, properly gauge every single aspect of an oral motor exam. … I can’t palpate a swallow. I can’t listen to breathing. Those types of things really did impact whether I would suggest a telehealth session in place of a direct face-to-face session (104).

Discussion

The COVID-19 pandemic prompted unprecedented changes to the provision of healthcare globally, leading to the large-scale use of telepractice as an alternative service model to overcome the physical barriers to accessing care. Thus in 2020, allied health professionals were thrust into telepractice as the primary service delivery model. This study aimed to explore the perspectives of a cohort of Australian speech-language pathologists, occupational therapists, and dietitians providing paediatric feeding services during the rapid adoption of telepractice during the first wave of COVID-19 in Australia.

Just over half of the participants in our study had some level of experience with providing telepractice before COVID-19, while the remainder had no experience. This is in contrast to other studies, which reported that pre-pandemic multidisciplinary management of children with acute and chronic paediatric feeding disorders had predominantly been provided in-person (Rozga et al., 2021; Ward et al., 2022). Several participants with more limited experiences talked about the need to learn telepractice by trial and error due to the rapid speed of transition away from in-person services, a finding reported elsewhere in the allied health literature (Malandraki et al., 2021; Raatz et al., 2020; Wittmeier et al., 2022). While learning by trial and error was a necessity for these clinicians, concerns have been raised over the potential for a lack of expertise in telepractice to impact negatively on patient care (Jonnagaddala et al., 2021), a legitimate concern given telepractice requires special skills (Mansuri et al., 2022). Furthermore, inadequate training in telepractice has been linked to a lack of self-efficacy and confidence (Grant et al., 2022). This issue was evident in the study participants, who were initially nervous about using telepractice for paediatric feeding but their confidence improved with experience and exposure.

Much like the clinicians in our study, the desire for formal telepractice training is high. For example, a study by Mansuri et al. (2022) of 456 speech-language pathologists found that 90% were interested in receiving training on how to provide telepractice to patients. Occupational therapists and physiotherapists also acknowledge the need for formal training in telepractice (Grant et al., 2022; Wittmeier et al., 2022). In contrast, despite their limited experience with telepractice, a survey of over 2000 dietitians in the USA found that 45% did not consult any guidance on how to provide clinical nutrition care via this method of service delivery (Rozga et al., 2021). Specific to our study population, Raatz, Marshall, et al. (2023) highlighted that Australian allied health professionals working in paediatric feeding prefer hands-on training that includes case discussions, videos, and feedback on their clinical practice. Together these findings suggest that organisations should take a formal, proactive approach to the transition to telepractice. Frameworks are available to inform this transition such as those proposed by Snodgrass et al. (2017) and Thomas et al. (2022). This transition should include the development and implementation of organisational policies and procedures and technical support for telepractice for paediatric feeding services, such as the system architecture for conducting paediatric feeding assessments via telehealth proposed by Raatz et al. (2019).

The shift from hands-on management of feeding to parent coaching in the online environment was a struggle for our participants who lacked prior experience with coaching. Despite this initial struggle, the clinicians appreciated the benefits of this family-centred approach. They reported that they had more success with frequent shorter sessions using a coaching model to build parental capacity and engagement, which they felt facilitated greater progress towards intervention goals. This finding aligns with the literature on telepractice-based training and coaching as an effective modality to improve family engagement with children receiving treatment for complex communication needs (Douglas et al., 2021) and which achieves therapy goals (Gerow et al., 2023). Telepractice can achieve the level of rapport found with in-person care of paediatric speech-language pathology patients (Freckmann et al., 2017), and has been shown to promote confident and engaged families in paediatric feeding (Peterson et al., 2021) and developmental disability (Peterson et al., 2021). Moreover, a survey of Australian speech-language pathologists engaged in paediatric feeding via telepractice by Raatz et al. (2020) found more relaxed children and parents, improved carer engagement, and strong support for parent/carer education.

Aligned with the study participants’ perception that parent coaching enabled the family to become the catalyst for change was the value of observing the naturalistic context during telepractice consultations for paediatric feeding, a finding supported by research (Peterson et al., 2021; Raatz et al., 2020). Participants reported that viewing the naturalistic environment synchronously during feeding provided the opportunity to observe not only socialisation in the home with fathers, siblings, and other relatives, but also observation of distractions, food, and equipment (e.g. highchairs, bowls, and spoons) used within the home environment. These observations enabled the identification of factors that could negatively impact feeding and those that promote feeding skills and behaviours to be tailored to family and child preferences, which were not always considered in patient care (Clark et al., 2019). The benefit of being able to observe the child in their natural home environment has also been cited in a scoping review of telepractice in paediatric occupational therapy (Önal et al., 2021).

Allied health disciplines report differences in the suitability of telepractice depending on the presentation of the patient and the role of their profession in feeding. Occupational therapists and dietitians within this study reported confidence in seeing clients for both assessment and therapy via telepractice. This finding contradicts a study of 230 occupational therapists in the USA, of whom only 4% reported telepractice to be effective with feeding in comparison to 84% for generic paediatric assessment (Dahl-Popolizio et al., 2020). Aligned with clinicians in our study, 27% felt telepractice could be used for caregiver education and coaching (Dahl-Popolizio et al., 2020). However, the health system in the USA differs markedly from the Australian health system so the applicability of these results needs to be interpreted with caution. Önal and colleagues (2021) conducted a scoping review of telehealth in paediatric occupational therapy practice. While they found 12 studies from the USA, nine from Australia, and one from Denmark, none mentioned paediatric feeding in their study population. Similarly, the dietetics’ views differed from one survey study of over 2000 USA dietitians, most of whom were reluctant to conduct typical nutrition assessments or monitoring via telepractice (Rozga et al., 2021). These survey respondents strongly supported telepractice for nutritional education and counselling, suggesting a more nuanced understanding is needed of the components of paediatric feeding occupational therapists and dietitians are confident to deliver via telepractice and which are best undertaken in person within a clinical environment.

In contrast to these allied health professions, speech-language pathologists in our study felt telepractice was only suited to medically stable, conservative management of paediatric feeding patients who required therapy; not for assessment, which they felt needed to be conducted in person. Lack of proximity was a key concern for these clinicians, who felt patient safety was at risk when they were unable to palpate during swallowing or listen adequately for signs of pharyngeal dysphagia during telepractice appointments. This finding aligns with a 2020 study of Australian speech-language pathologists that found only 38% used telepractice for initial assessment, 63% for therapy, and over 95% used telepractice for parent and carer education or progress review (Raatz et al., 2020). Similarly, Manickavasagar et al. (2021) found most clinicians (67%) did not feel that telepractice was appropriate for new patient consultations, due to the inability to conduct physical examinations. However, other studies have reported high levels of confidence in speech-language pathologists’ ability to assess patients’ swallow via telepractice (Burns et al., 2019; Malandraki et al., 2021; Raatz et al., 2019), including more recent studies by Raatz and colleagues (Raatz et al., 2021a, 2021b) who found a high level of agreement between telepractice and in-person assessment in both paediatric feeding and bottle feeding when using a structured assessment protocol. The exceptions to this were intraoral examination (e.g. palate integrity), gagging during non-nutritive sucking, and components of a tongue-tie assessment. These exceptions, along with clinicians stating they were less positive about providing feeding services to neonates/infants via telepractice than older children, further support the need for a hybrid approach to paediatric feeding that carefully considers when services are best delivered in-person and when they can be delivered via telepractice (Raatz et al., 2020).

Limitations and future research

A key limitation of this research was that it was a small-scale study undertaken in one Australian state at one time point early in the pandemic, so the findings may not be representative of the experience of allied health clinicians in other states or in other countries where the impact of the pandemic varied widely. The heterogeneity of the study participants (all female) may also impact the generalisability of the study, particularly given the different experiences of female and male health professionals during the pandemic (Morgan et al., 2022). The study would have benefitted from capturing greater detail on the participants including their years of experience as health professionals, years of experience with PFD, and area/s of practice within paediatric feeding and swallowing that they are regularly engaged in. Future research should consider a larger sample size with greater diversity in gender, level of clinical and telepractice experience, and location. Research is also needed to explore the suitability of telepractice for different client populations, including culturally and linguistically diverse and Indigenous families. While a promising cost-benefit analysis of speech-language pathology paediatric feeding has been conducted (Raatz, Ward, et al., 2023), further such analyses are needed, including the impact on workload (e.g. clinician training and preparation hours, and mental load), and the engagement of fathers and other family members.

Clinical implications

In the future, organisations should take a formal, proactive approach to telepractice rather than the ad hoc, trial and error approach experienced by our study participants. Frameworks are available to inform the transition to telepractice (Snodgrass et al., 2017; Thomas et al., 2022). This transition should include the development and implementation of organisational policies and procedures and technical support for telepractice for paediatric feeding services. It should also include training in telepractice and in parent coaching to deliver safe, high-quality paediatric feeding services. Consideration of the suitability of telepractice for an individual patient, to determine whether telepractice is the most suitable modality for service provision, as well as considering the client’s current medical and nutritional status, feeding, and psychosocial considerations is also important.

The wellbeing of the health professionals must be factored into any such planning (Søvold et al., 2021), along with guidance for clinical decision-making about the suitability of telepractice for specific populations.

Acknowledgements

We would like to thank the Disability Services Commission, trading as the Department of Communities, for supporting Denise Imms’ participation in this project.

Disclosure statement

All authors certify that they have no affiliations with, or involvement in, any organisation or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.

Appendix A.

Reflections on telehealth services for paediatric feeding disorders

Semi-structured interview questions

Background/experiences/perspectives

• Tell me about the client groups that you see and the services you typically provide.

• Tell me about your experiences and perspectives of telehealth before COVID-19 (before March 2020)

• How many children have you seen/sessions conducted for feeding and swallowing assessment and management through telehealth before and after COVID-19?

• What are your current thoughts on telehealth as a service delivery model for paediatric feeding?

• What factors influence whether telehealth is an appropriate model of service delivery?

Planning

• How does your planning for telehealth differ from face-to-face sessions?

Technology

• What technology are you using for telehealth?

• What technology are families using?

• What platform/s do you find most effective?

• What other equipment do you use? Microphones/feeding materials?

• Have you or your clients encountered any technological barriers and what have you done to overcome them?

Clinical session

• What do typical telehealth mealtime management assessments and intervention sessions look like in comparison to a face-to-face session?

• How confident were you with your observations and clinical decision making?

• What modifications have you made to the direct, hands-on aspect of assessment and therapy for telehealth? E.g. completing an oral motor examination, examining reflexes, the strength of movements, trialling textures, modifying equipment, and positioning.

• Do you implement any additional safety precautions beyond what you do for face-to-face delivery?

Reflection

• Have your perspectives and practices in telehealth changed over the past four months?

• Do you plan to continue to use telehealth delivery for paediatric mealtime management?

• How have the children and their families responded to telehealth sessions?

Overall

• Tell me about any surprising benefits or challenges.

• Reflecting on your experience, what advice would you give clinicians wanting to start providing telehealth services to this population?

• Is there anything else you would like to share?