Am I Looking at a Feeding Problem or an Airway Problem?

Sometimes we interpret these things through a behavioral lens. The kid's avoidant, they've got sensory sensitivities, they need systematic desensitization, et cetera, et cetera, et cetera. And while that might be true for some kids in some situations, here's what you need to realize. If the root cause is airway, you are spending months on therapy and probably thousands of dollars on therapy that could be a lot cheaper and so much faster if you actually address the underlying issue, the breathing. Welcome back to the Untethered Podcast. Today it's me, your host Hallie Bulkin, And I want to talk about the airway piece that your feeding cases are missing. So let's jump in.

Welcome to the Untethered Podcast. I am your host, Hallie Bulkin. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner, and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up-to-date information in the orofacial myofunctional therapy, airway, tethered oral tissue, and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest posture, tongue up, lips closed, teeth apart, breathe through your nose. Let's get started.

All right, so I wanna start with a question that I think might make some of you a little uncomfortable, and that's the point here, okay? How many feeding cases are you working with right now where you've never actually screened the airway. And I'm not talking about a casual glance. I am talking about a systemic, intentional look at what is happening in that whole connected system. Okay? The airway, the jaw, tongue, posture, right? The whole thing. Okay? Because here's the thing I've noticed over 350+ episodes here on the podcast and oh my gosh, 7 years of podcasting. Holy moly, feeding therapists and arguably myofunctional therapists, right? Really, really good feeding and myotherapists are missing a critical piece of the puzzle. Yes, even some of the myotherapists. And it's not because you're not smart. It's not because you don't care. It's not because nobody told you what to do or not to do. Actually, probably because nobody told you to look there, right? Nobody actually taught you that your feeding case or even your myo case— sometimes this happens in myo courses, you'd be surprised— might actually be an airway case. First. Okay, so today we're talking about the airway piece, and I'm going to just keep saying for your feeding cases, but this really goes to any case that you might be treating because this is the airway piece your feeding cases are missing. All right, now I'm going to talk you through why this matters, what you're actually looking for, how this connects to the whole rest of the system, especially the mouth breathing, the postural piece, the feeding connection that I think that most clinicians just don't see coming. If I'm being honest. All right. So let me ask you this. What if 40, 50, I don't know, 60% of your feeding kids also have a significant airway obstruction? What if, right? And what if you could identify that and then refer it out appropriately and actually see your feeding therapy outcomes shift completely? Okay. And this is not hypothetical. This is what I actually see clinically, and I want you to see it too. Okay. So let's just jump through like why this happens first. Because I think understanding the why helps you take action differently. So feeding therapy training, right? Historically, it's mouth. It's focused on the mouth. And you learn about oral motor skills, tongue placement, swallow mechanics, sensory processing, like all the things that are super important. Those are all crucial pieces of the puzzle, but the system that mouth sits in, the airway above it, the postural support below it, and arguably, yeah, mostly below it, right? Those don't always make it into that foundational curriculum. Unless you take my course. So you graduate from grad school, you're maybe you're trained to see feeding mechanics, if you even got that, because so many of us get zero pediatric feeding training and your lens on which you were trained there, or maybe in some post-grad courses, right? That's how it's calibrated. And that makes sense, but it also means that you're missing potentially what's actually driving the feeding problem in the first place. So I wanna give you guys a really concrete example. So I had a 3-year-old come in to our practice last month for feeding therapy. Mom reported picky eating, slow feeding, some gagging, pretty classic feeding referral, right? And the previous clinician was really competent, by the way. I actually know the person, but they had been working on oral sensory motor skills, desensitization, texture progression for 4 months with minimal progress. And when I took a look at this kid, the first thing that I noticed was mouth breathing, right? Chronic mouth breathing. And then I looked at the palate— high, narrow, really constricted, right? There was a forward head posture, there were elevated shoulders. We looked at sleep history. Dad had sleep apnea, loud snoring, which doesn't always mean it's going to trickle down to the child, but okay, so at least I have an understanding in this family, right, of how important sleep is and how impacted it can be. So that's a good starting point there. And when my team and I actually did the basic airway screen, It was obvious this kid had significant obstruction right now. We can't diagnose all of this ourselves, but we knew that there was probably some adenoid hypertrophy, maybe some tonsillar enlargement. And this child has been in feeding therapy when the child actually really needed an ENT appointment. Okay, now did the therapy hurt the child? No, but it wasn't addressing the root cause. And here's the kicker: once airway gets addressed, whether that's through medical intervention myofunctional therapy depending on the age of the child, maybe positional changes, potential intervention with orthodontist or airway dentist, right? Feeding therapy actually works so much better because you're not trying to fix feeding while the nervous system is in sympathetic dominance from breathing struggles, right? So why do we miss this? Okay, there's a few reasons. For one, you're just not trained to screen for it. It's not part of the standard SLP curriculum or OT curriculum for most programs, right? If they even teach you, like I said, if they even teach you any of this at all. Airway screening just feels like it belongs to an ENT, to sleep medicine, to pulmonology, right? Not to you, except it does. It belongs to you because it affects every single child you're treating and everything you do. All right, number 2, why we miss this. It's not obvious, right? Airway obstruction doesn't always present as a classic sleep apnea symptoms. So it's subtle on some kids. It's subtle on some adults too. Maybe it's a kid who mouth breathes during the day and there are slightly enlarged adenoids that technically don't appear to be that bad on a sleep study or on imaging. And then as far as the symptoms go in a sleep study, it's maybe there's postural compensation. It doesn't look like much until you know what you're looking for, right? And so it's just not obvious. All right, and number 3, one of the biggest things is that you're not asking about it. You're not on a standard feeding intake going, hey, does your child snore? Do they ever wake up gasping? Can you hear them breathing through their mouth? Are they breathing through their mouth during the day? Do you hear them breathing during the day? Do you hear them breathing at night? Breathing should be silent, my friends. Are they really restless sleepers? Do they have neck tension? These questions are not automatic. You have to be trained and you have to know what to ask. And so the first piece of this work is permission and awareness, right? Because you need to know that screening airway is part of your scope, cuz it is, and it's connected to everything you do with feeding and you need to make it part of your standard protocol. Period. End of story. All right, so let's talk about airway obstruction, what that actually looks like, like when a kid comes in for feeding therapy. Okay. What are the presentations that should make you pause and think, hmm, wait a second, is this actually an airway issue? Or could there be airway issue present? So I want to talk about the physical presentations first. Okay, mouth breathing, that is a big one. Chronic persistent mouth breathing, not just when they're playing hard, but during quiet play, during meals, in between bites and swallow, and chewing and swallowing, during sleep, especially during sleep. When you see that, your first thought should be, why isn't this kid breathing through their nose? And usually there's some type of airway obstruction somewhere in that equation. Okay, along with that, you're also going to see potential postural changes. So that forward head posture is almost— it's almost always present in kids who have been not breathing for a while. We start to see them push their head forward, push their jaw forward. Their neck is on an angle now instead of sitting straight up. And so that forward head posture is almost a marker. The kid who holds their head forward, who doesn't have a great— who doesn't have great control over their core, great core activation, who might have some actual kyphosis like developing already, that posture is existing because the nervous system is trying to open the airway and the body's always going to take the path of least resistance, my friends. Like, hi, I am a head forward case where my head, my ears sit further forward than the center of my shoulders, right? That's a really good easy way to tell is like where that you're sitting in relation to the shoulders. If the ears are further forward, You've got a head forward posture and you gotta go, mm, okay, we need to assess airway. Palate shape is also something that tells you a lot. A really high narrow V-shaped palate, or even like a U-shaped but really high narrow U-shaped palate, that is often airway obstruction talking. The palate is going to remodel in response to how the child is breathing and where the tongue is living in their mouth. Okay. Which brings me to tongue position. So the tongue is either positioned low and back trying to make more airway space, or it's rigid, it's tense, it's racing, right? And clinicians, a lot of us are usually like, oh, we need to work on tongue mobility and strength. And while that might be true, maybe that is the answer, you also need to ask, is the tongue doing this because the airway is compromised? Okay, now let's talk about gag reflex. And by the way, a gag reflex is something that we don't want to eliminate. It is a protective mechanism. It is protecting the airway, but we want it to be towards the back third of the tongue. We don't want it towards the front third or the front half. So when we have a really strong, easily triggered gag reflex, Sometimes it isn't actually a sensory processing issue. Sometimes it's a protective airway reflex. Okay. And again, we don't want to eliminate it, but we do want to move it further back. But if we're having trouble moving it further back, let's look at the airway and maybe even temporal tissues. Conversation for another day. Right now, let's talk about like feeding-specific signs. Okay. So if picky eating is present or food, they're very selective with their foods. Is that selectivity happening because the soft foods do not require as much work? They don't fatigue the child as quickly when they're working just to breathe. That could be the case, right? And if they're slow feeding at play, what if that's because coordinating the breathing and the swallowing is compromised? What if the child is coordinating 3 things, breathing through the mouth, managing the food, and trying to swallow instead of the normal 2? Because if we're nasal breathing and we're more easily able to manage the food and our swallow, that whole process. That takes a lot less energy and coordination is a lot easier. Gagging and coughing during meals could also be— I want to add this— could also be the child is aspirating slightly because their airway dynamics during swallow are compromised by an obstruction. Now, I don't see aspiration as much, like, in our kids. Obviously, kids with medical complexities, that's definitely more of a concern. But in the kiddos who don't have those other medical complexities, I'm not typically seeing a lot of aspiration happen, but it is something that we do need to rule out. Okay. And then the whole, like, all the sleep and behavior stuff. Does the kid sleep restlessly? Are they snoring? Are they tired during the day? As I mentioned some of this earlier already, right? Because that sleep, that fragmented sleep, even like mild obstructive sleep apnea or sleep disorder breathing, that affects everything. And Christian Gamino, who created that sleep apnea spectrum for the AHI, like how many moments are happening, sleep apneic moments are happening, like in an a certain period of time. He shared towards the end of his life, he shared that he regretted actually making that scale because the medical system now treats like mild and even sometimes moderate sleep apnea as normal. And mild, even mild was never meant to be a typical thing, especially in pediatrics, especially in children. So if there are any apneic movements, if there is mild, if they're diagnosed with mild sleep disorder breathing or mild sleep apnea, that, that requires intervention. So I just wanna put that out there. Okay. And here's the thing that also really gets me that I feel like I need to wrap up with before I give you like a framework through which you can screen for this quickly. Sometimes we interpret these things through a behavioral lens. The kid's avoidant, they've got sensory sensitivities, they need systematic desensitization, et cetera, et cetera, et cetera. And while that might be true for some kids in some situations, Here's what you need to realize. If the root cause is airway, you're spending months on therapy and probably thousands of dollars on therapy that could be a lot cheaper and so much faster if you actually address the underlying issue, the breathing. Okay? So this is critically important that we look at this in every single one of our cases so our families are not wasting time and money in therapy with us. So what to screen for? Now you're thinking about airway, hopefully after that nice intro into it. So what do you actually look for? I'm gonna give you a framework I use. I call it the FAST screen, okay? The Functional Airway Screening Tool. F is for functional presentation and face. Ultimately, A is for airway, okay? The anatomy. S is for sleep history. And then T, we look at tone and tension. And I kind of shifted this a little bit because I had those letters standing for slightly different things on my initial FAST. S was for sleep, but also for speech, which we can still keep it there. T is for tone or tension, or even like tethered oral tissues. But anyways, and tongue, right? All these Ts. But the bottom line is it's FAST. Okay, so it's a functional airway screening tool. And let's talk about that functional presentation, the F first. Okay, so do you observe chronic mouth breathing? Is there a forward head posture? High narrow palate? Is the tongue position looking braced or low or back? Do we have any obvious nasal obstruction that you can actually visualize? That's what I'm looking for. Function. Okay. It's like I said, I shifted some of these things around a little. A is for airway anatomy. Do the tonsils look enlarged? We can visualize those tonsils in the back of the mouth, right towards the throat. Can you see the back of the throat or is it really crowded? Is the tongue sitting really high? Are the tonsillar pillars filling a lot of the airway space? What does the overall throat space look like? Okay. And then S is for sleep history. Ask the parents directly, does a child snore chronically? Do they wake with gasping, with choking, apneic pauses? Are they sleeping restlessly like I mentioned before? Have we witnessed any apneas? Is a child tired during the day? Are they hard to wake, right? Like we need to know not just like how many hours they sleep, that quantitative amount is not actually telling us as much because if the quality of that sleep is not good, we've got a bigger problem at hand, okay? I mentioned tone and tension is how I've reframed this. And so is there elevated tone in the neck, the shoulders, or the jaw? Or are they doing a lot of bracing? Are they lower tone, right? Do we feel any tension in the submental area around the hyoid? Is there restriction in cervical mobility, right? These are things that we can be screening for, and that's it. Like, I do have a whole FAST screening that you can download for free and everything, but if you just want a super quick thing, this is what I would be looking at. This is it. That's your screen. It takes maybe a couple minutes once you know what you're looking for. And if you see two or more red flags right across these categories, you document it, maybe you refer to the ENT, maybe you refer for intervention with you, right? But that collaboration with the other providers who may be really beneficial to the case, like, that collaboration is huge and it's really important. You don't need to be the expert in everything. I want to make sure I say that. Like, you are not diagnosing sleep apnea or tonsillar hypertrophy. You need to recognize the pattern enough to know that this might be an airway thing, and it also may need to be looked at by somebody who specializes in that. When a child breathes through the mouth chronically, what I want to point out is there's 3 things that happen to the whole system, and I really want to hang tight on this for a few minutes, and then we'll talk about like when and how to refer and how to integrate this into your practice. Okay, when they're breathing through the mouth chronically, 3 things happen to the whole system, right? As I was starting to say, one, the tongue loses its normal resting position. When you're mouth breathing, the tongue drops, it hangs low and back and the tongue is low and back instead of being up and forward. Okay, and this is going to change the feeding mechanics, like it's going to change it immediately. The tongue can't generate as much force for bolus formation. The swallowing patterns shift. Maybe they can't generate the negative pressure because they can't suction the tongue to the palate to create that negative pressure. So the positioning of the jaw and the tongue in relation to where this food bolus is, or the scattered bolus potentially, right? This all starts to shift, right? Okay, so that's number one. Two, Postural changes also develop. So the head comes forward like we were talking about earlier to maximize that airway space and the ability to breathe. The jaw is going to drop, the hyoid and the larynx migrate lower as well. Everything is off. Everything is off. Okay. And 3, there's compensatory tension that starts to build. So our SCM or sternocleidomastoid, my favorite muscle, it's my favorite muscle. I was telling my kids this at dinner the other night. They think I'm so weird. Submentalis, the mylohyoid. These, they're all working really hard. Okay. But they're also bracing. And so we tend to have kids who sometimes develop stiffness in their neck. Maybe they develop some tension in their jaw and they guard during feeding. They're actually very tense. So we need to be looking at that as well, this compensatory patterns and tension that builds. And here's a case that shows us really clearly. I wanna share this case with you. I had this 2-year-old chronic, they actually were choking on solids, which we don't always see choking as frequently. Lots of gagging too. Mouth breather, clear signs of obstruction. Okay. And so I referred to an ENT. It turned out that the child had significant adenoid hypertrophy. While waiting, I worked with mom with positional strategies. Within 2 weeks, choking decreased. Within 4 weeks, gagging decreased significantly. And then post-surgery, we made 6 months of progress probably in 2 weeks because the airway was now open and the whole system could actually organize differently. Now what I want to tell you is I don't get a ton of cases where kids are choking. This was a unique case. Usually it's more gagging than choking, but this was a really interesting kiddo. So when and how to refer? So first, ENTs are going to be your besties. You need to find good ones who understand what we do and why you're referring. They need to be— we need to refer to ENT for medical assessment, okay? I— you can say something like, I noticed in my eval that breathing might be playing a role in feeding, in the feeding picture. Would love for ENT to do an exam so we can make sure that we're addressing everything. Now that may not be specific enough. You are probably gonna wanna say, here are the signs and symptoms I'm seeing in this child. They are reportedly apneic during sleep. They're snoring. There's daytime sleepiness, mouth breathing. You know, you're gonna list these things out because that is how the ENT's gonna know what to look for and they're gonna then know, oh, okay. And you can even say, you know, I'm referring because it would be great to have a scope or scan, a visualization of things that I cannot see. With my eyes. And obviously you have to have a relationship with an ENT to suggest things like that. So go build those relationships, my friends. Another consideration might be sleep medicine. Now, I really don't refer to sleep medicine for pediatrics. This is more for adults, or if we have a sleep history that is extremely concerning, or maybe an ENT who— maybe there isn't a great ENT in your area, so maybe there is sleep medicine who does work with pediatrics. But typically I'm referring to ENT, especially for witnessed apneas any severe snoring, daytime sleepiness, like all those things I mentioned, right? And then the other referral would be myofunctional therapy if the child is over the age of 4 cognitively. And here's the thing, myo is not a replacement for medical care. It is part of the medical care plan. There may other be, there may be other pieces that we need to refer for as well because it's a really essential part of our treatment, right? But even after a medical intervention with maybe an ENT or an airocentric orthodontist or whatever, We have to retrain that whole oral myofunctional system. Okay? And so it is a critical piece of the puzzle. Your referral pathway, airway's gonna come first. We have to identify the airway concerns first so then we know if we're referring to ENT, are we starting myo first or pediatric feeding, right? And if you're trained in Feed the Kids, my program, and the kid is under the age of 4, then you will know exactly what to do with these kids 'cause we're still addressing all the myo goals. I call it pediatric feeding with a twist of TOPS and MYO, right? You're still addressing that stuff. So depending on the age of the kid and depending on your training will depend on that referral pathway and when it's most appropriate to either start pediatric feeding, start MYO, refer to ENT, or refer to another provider. Okay. And what I wanna tell you is, you know, even in these cases where a MYO might be helpful, if there is a history of pediatric feeding concerns, that child still, we need to keep our pediatric feeding hat on. Even if they're over the age of 4. It's not— MYO is not just like the end-all be-all, right? It's really important, and for some kids it might be enough, but for others we may still need to take a combined MYO feeding approach. All right, so how do we integrate this into your practice? We're going to add airway screening to your intake form first, okay? You're going to ask questions like, does your child snore? Does your child breathe through their mouth during the day? Do they, like, when watching TV, like passive things, right? Watching TV, riding in the car, like when they're not eating or speaking. Does your child breathe through their mouth when sleeping? Is their mouth open when sleeping? There's certain questions you wanna ask because parents might go, no, they don't breathe through their mouth. And then they send you a 3-minute video and you're like, that child's mouth has been open the whole time. They're breathing through their mouth. Is there any history of sleep apnea in the family? Right? It could be helpful to ask about that and know about that, even though it may not be directly connected, but it could be. And then during your oral motor assessment, I want you to add in airway observations. What's the breathing pattern? What's the head position? What does the overall airway space look like? Just as simple as that. And then I want you to add this to your— I actually want you to add this to your assessment document if you use one. Make it explicit, like airway patent, no significant obstruction, or airway evidence of obstruction noted or concern over obstruction, refer to ENT, right? Recommend ENT eval, what— however you want to say it, right? When you start looking for this stuff, you're going to find it, I promise. And it's not that I'm I'm not telling you this because we, we are trying to like over-diagnose kids. That's not a thing. If there's an airway issue present that you're missing, you're gonna find it when you know what to look for, and then you're gonna help the kid get the intervention they need. And guess what? Your therapy as an SLP or OT or PT or whoever is going to be so much more efficient because we address the airway first. So I'll just wrap it up here. Okay, so let's kind of recap this, right? Number 1, feeding therapists are in a unique position to identify airway obstruction. You can screen and you should. Right? Number 2, airway obstruction affects feeding in specific ways. Mouth breathing repositions the tongue, it changes posture, it creates compensation patterns. And so a simple FAST screen like I went over with you guys takes about a couple minutes, gives you critical information, and then you have a better idea of the referral pathway, right? And listen, I don't refer off of screenings oftentimes unless I have not like significant airway concerns from the screening alone. And so in that case, you might be going straight for ENT for medical management, right? Or you might be starting MYO or pediatric feeding and taking a whole system approach, and then that referral may come later. And then you're going to add this to your standard protocol, right? And that doesn't take extra time. It just— you just have to be super intentional and put that one thing that I just mentioned on your feeding assessment protocol. Okay? Ours have it. So if you have ours, you're good. But if you don't, add it to yours. It'll be super helpful. All right. So the one thing I will say is go ahead and make sure you download— we'll make sure it's linked around the episode somewhere— the FAST/MYO screening packet. Oh, actually I remember the URL. You can go to fastmyoscreening.com. It's free. Print it out, put it in your next intake. And I want you to message me about what you find, like my Instagram @HallieBulkin. I am the one in my DMs. So pop in there, tell me that you downloaded it. Tell me how it's going. Let me know if you have questions, right? And if you're thinking like, okay, but what about the myo piece? That will be the next episode that I do myself. We'll do a Myo 101 for feeding therapists. And I wanted to kind of demystify what that actually is, why it matters, and how it fits into what you're already doing. All right guys, thank you so much for being here. I will catch you on the next episode. Quick disclaimer: all information, content, and material of this podcast are the opinions of the speakers and serves as informational purposes only and not intended to serve as a substitute for the consultation, diagnosis, and/or medical treatment of a qualified healthcare provider.

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