Ep 337: Unlocking Pediatric Feeding: Expert Strategies with Hallie Bulkin

Are they snoring? Do we think they have allergies? You know, because maybe they have those allergic shiners or those dark circles under their eyes, you know, are they bedwetting? High airway? So we start to look at these things that really matter that a lot of people are not connecting the dots on. And we teach you how to connect the dots between, like, airway and feeding. Because again, this is just not talked about enough. Hi and welcome to episode 337 of the Untethered podcast. I am Hallie Balkan, your pediatric feeding mentor and creator of Feed the Peeds. And. And today, today's episode, it's going to be a little bit different because it's part masterclass, part story time, and part invitation to take your pediatric feeding skills to the next level, my friends, because. Drum roll, please. I can't even talk. The doors to Feed the Peds, my signature 12 week course, are officially open. And this, my friends, is your opportunity to get mentorship, community and evidence based tools that actually make sense in real therapy skills sessions. But don't worry, this episode is not going to be all promo. I am walking you through how I think about feeding from assessment to treatment, and why these two parts need to work together and not in isolation. And that is going to be the masterclass today. So let's kick things off. Welcome to the Untethered podcast.

I am your host, Holly Balkan. 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, tepidural 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.

Okay, so let's kick things off with a big myth that I see over and over and over again. And that, my friends, is that a feeding assessment just means that watching a kid eat and documenting their skill level means, like, you've assessed the child. And that's. That's like trying to diagnose a breathing problem by watching somebody walk. Like, I know that sounds silly, but, like, I want to break down what a real pediatric feeding assessment looks like. Okay, so number one, we need to have a case history and an intake interview. Right? Because the parent interview that we have, especially for our youngest ones, like that is gold. That is such good information. It's going to tell you about, like, do they fatigue? What about anxiety, positioning, you know, and I just did an episode where I talked about how important positioning is recently. Um, it was brief, but it was powerful. You know, meal dynamics and even like hidden patterns that explain behaviors because, you know, we'll hear things from parents like, you know, my child eats better in the car. Well, that's an airway flag, right? Or we distract them with a tablet. Okay, Maybe their feeding is a little dysregulated. Why do we need, you know, I'm not saying take it away, but like, why does that child need to be distracted with a tablet or whatever the tool may be, you know, they're using to distract. So we teach you how to extract those red flags that parents maybe don't even realize they're telling you, but that kind of make you go, hmm, okay, there's something more going on here. I want to dive a bit further into this. Right? So that case history, that intake interview that follows, that is such critical information that I think is ignored way too often because people are not really trained on like, hey, how do we actually dive into this? And how do we take this information and ask follow up questions and then holistically look at everything we're seeing. The parent is telling us like all the things, right? To figure out what's going on, what needs to happen next, what might the treatment plan look like if therapy's recommended, and so on and so forth. Right? Okay, so that's part one. Part two then is that oral motor examination. And we're going to look at both structure and function because it's not just about like whether they can move their tongue, how do they move their tongue, how long can they do things, Are they fatiguing? Like, are they coordinated, are they using their jaw to support their tongue? Because, you know, by, I don't know, 18 months, right. If you guys were part of my training last week, you know that by like 18 months of age you should have a child separating the use of their tongue from their jaw and their lips. But we don't get that dissociation, that jaw lip, tongue dissociation. And a lot of the kids that are coming to see us for an evaluation. So understanding that, Right? And so the tongue lateralization, for example, like, we want to assess that, but also, let's have a snack with the kid and let's see what they do. Do they clear their lips? Do they move the tongue one way or the other? How is their jaw grading? What does that look like? And then, like I mentioned, like, dissociation of the tongue, lips and jaw from each other so that they can actually chew, prep the bolus, put it on the center of their tongue, swallow. Right. Are they able to do all these things? Oftentimes my. I'm going to, I'm just going to guess, venture a guess for you that they're probably. The dissociation is probably not there. Very, very common in kids older than 18 months that are seeing us, many of whom can't lateralize their tongue because that goes hand in hand with not being able to use a to separately from the jaw. They tend to move the jaw and the tongue together and the jaw grading, you know, how wide they open their tongue, which you don't need to open it too wide, but are they opening it wide enough to take a bite of the food they need to bite? And then also, like in the chewing patterns are like, what does that look like? So that oral motor exam is extremely important. But like, a lot of people just focus on structure, and we like to marry structure and function together because we need to know, like, the how, the, you know, you know, the how behind it, essentially. Right, Like I said, it's how, how long, how fatigued, how coordinated they are, et cetera. And then number three, this is a big one that most people don't do, but I dive into, like, the tots, the tethered oral tissue and the myo side of things, like the upper airway stuff separate from like, the lower airway stuff that we're used to learning about in peds feeding. I separate that out in my TOTS and MYO modules and really dive into, like, how do we screen the airway? Like, how do we dive into, like, what might be going on from an air airway perspective? So, like mouth breathing, Is there open mouth posturing when they're not, you know, chewing or speaking? Is there sleep disorder breathing present? Are they snoring? Do we think they have allergies? You know, because maybe they have those allergic shiners or those dark circles under their eyes, you know, are they bedwetting high airway? So we start to look at these things that really matter that a lot of people are not connecting the dots on. And we teach you how to connect the dots between, like, air, airway and feeding. Because again, this is just not talked about enough. And it's definitely not a part of common assessments, but it needs to be regardless of the age of the child. Okay. And then the next thing is the sensory side of things and the whole, like, sensory versus, like, motor. Like, root cause analysis, if you will. Like, do you have a picky eater who only eats white, crunchy carbs? Is it sensory or oral motor fatigue or is it both? Right. Is it a sensory kid who hates to brush their teeth? Um, maybe. Do they have undiagnosed tethered oral tissues? Maybe it's causing discomfort. Maybe they just have limited range of motion in their tongue. Right. There could be a whole host of things going on. And so we kind of need to dive into that. You need to know the difference, otherwise your treatment plan is going to miss the mark. Now, that said, we do not treat things in silos because everything is so highly interconnected. But you still got to figure out, like, what is the symptom and what is the root of the symptom? Like, what is leading to that? Because oftentimes what is taught in most courses is, what are the symptoms? Okay, let's treat the symptoms here. We're going, what are the symptoms? What do we think is leading to those symptoms? Let's treat that. And it's not always super obvious, and it's not always what you think it is. And if you don't actually address that thing, you get those lifers who never graduate from therapy. But if you actually can figure out what the root cause is behind all these symptoms you're seeing, then we have a very different conversation going on. And we actually get kids who graduate out of therapy at a certain point. Okay. And then another really big component that I want to hone in on when it comes to assessment is parent coaching. Because I really feel like this is probably one of the most overlooked part of the assessment process. Like, a lot of people will talk about it, but they don't talk about it in a way that really makes you feel confident about how you speak to parents. So, you know, what we like to teach is, we like to teach that you need to speak to parents in their language, like, without overwhelming them. Think about how overwhelming you feel. Just learning the information. Now you're going to go and try and teach it to the parent of the children you're working with. Like, we gotta meet them where they're at. Right. But we also have to still, like, give them clarity around all of this and give them some, like, action steps. Like, we need them carrying out what the child's succeeding with at home for their home plan. Right. Their Homework, Right? So the goal is not just to, like, identify red flags and, like, show the parents, like, hey, this is what's going on. And that's what's going on. It's really to help parents understand what's going on on a deeper level so that they feel really empowered to, like, move forward with you as a part of the team. That is so, so, so critical. Okay, so let's dive into, like, treatment. That was our assessment. Okay, now treatment. I want to talk and really focus on how treatment. Treatment has to be functional. Right? You've done the assessment. What's next? Let's create a treatment plan, right? I feel like this is the point where so many therapists that we work with freeze. Like, we've talked to, maybe not work with, but, like, we talked to y', all, and you're like, okay, I can do the assessment. I got that. But, like, when it comes to treatment planning and actually starting treatment, carrying out treatment, knowing where to go next, like, that's where a lot of therapists are like, okay, whoa. Not so confident here, right? Or you're just not really sure how to turn what you've now observed into a treatment plan. And so I want to simplify that a little bit. So I'm going to break this down into, like, four different parts. Okay? So postural stability, I mean, airway always comes first, but I'm not going to dive into the airway thing right now. What I want to talk about, because we talked about airway a little bit on the assessment side. Um, but after that, postural stability is really, really important. And also it directly impacts airway. So they're kind of one in the same in that sense. But the whole, like, 90, 90, 90 thing, it's not just a guideline. It's more of a requirement. Like, if we got those wiggly hips, we got wiggly lips. And I mentioned this a couple episodes. What we see on the hips, we see on the lips. However you want to say it when. Whatever. Cute little phrase, poor trunk control, right? Your. Your trunk, your stomach, your hips, you know that's going to lead to poor oral control. So I want you to think of it like, trying to do, like, a bicep curl from a Bosu ball. Like, there is no stability. And when there's no stability, we don't make progress, Right? So we have to create stability. It's kind of like when you're building a house and you have a foundation, that foundation creates stability. This is the foundation, the stability. Like, postural stability is the foundation for the child. We need that in place in order to see progress in other areas. Okay? So just let that sink in. Also, if there's airway issues, that too, but conversation for another day. Okay, so the next thing is mouth prep, right? Mouth prep and then oral motor play. So warming up matters, right? It activates the system, it brings awareness, it preps the muscles. A lot of people are like, oh, we don't have to warm it up. I'm like, well, do you jump into a workout without warming up? I mean, I don't in my Pilates reformer classes. So, you know, and we cool down afterwards and do a little stretching. So these are muscles, like we are working with muscles of the orofacial complex. Why would we not warm them up? So warm ups matter. So please, please do that. Um, and that's where even things like people are like, oh, blowing bubbles. That's just the fun little game. No, we're actually moving the muscles around. Maybe it's not in the exact same movement we're going to use for feeding. However, it's still waking the muscles up, getting everything activated, bringing awareness. We're just, we're prepping, okay, we're prepping tongue pops, you know, lip rounding games, maybe biting some chewy tubes just to kind of like get things warmed up and then moving into that oral play as well, which no biting chewy tubes. And that kind of stuff starts to move more into that, as does like the lip rounding games. So, you know, it's. This is not just for younger kids. Like even those neurodivergent teens that you might be working with can benefit with the right buy in. So just like let that sink in for a moment. Okay? Now the next thing is food play with purpose, not just exposure. So if you're still offering like random new foods each week and just kind of hoping for the best, let's level that up a little bit. We like to use like, you know, modified food chaining, texture scaffolding, gradual oral motor shaping. So for example, what does that look like if they, they like puffs. Okay, Some kind of a puff. Maybe we go to a dissolvable veggie straw and from there we go to some kind of a soft crunchy. And from there we go to a crunchy raw carrot. Right. Do you see how I kind of like food chained it? We kind of scaffolded the textures and we kind of, you know, are able to then shape what we're presenting to them in a way that they can handle from an oral, a sensory, oral motor standpoint. Like, everything we do is intentional. And so the food play, like, you know, needs to be purposeful. It's not just for exposure. Exposure is great and it's important, but it's not the only thing we're doing. So I want, I want you guys to figure out like, like our goal is to get you out of just exposure. Because a lot of clinicians will come to us feeding. Therapists will say, well, we've just been playing with a lot of food or like, we've been doing a lot of exposure. But it's not moving beyond that. Well, why, why is the nervous system in rest and digest? Or are we like in fight or flight? How are we presenting these things? How are we chaining them? Like, what are we doing to make the child trust us and feel comfortable? Right. Okay, so that was a lot. But the last thing here is parent led practice at home. And I know a lot of you struggle with that as well, which is why I wanted to also bring this up. If parents don't know what to do at home between our sessions, we have failed them. I'm going to say that again. If parents don't know what to do at home in between sessions, we have failed them. Inside Feed the peas. Like, we give you, like, strategies and everything on how to basically help your families do this and fit it into their daily routines. Okay. Like, one therapist I remember told me she used to dread, like giving parents homework and now she builds it into literally every session. That's what we do in my private practice too. And her kids are progressing faster because of it. But it also, the onus falls on us to make sure that parents understand, understand why we're doing what we're doing and how, like, the one thing we're asking them to do is really going to reinforce the next steps and allow us to move forward next week. If they could just do like a few minutes of this next thing that we're recommending, like every single day. Right. And honestly, I usually give them something that the child was successful with in therapy so that they can now generalize that outside of therapy with somebody else in another environment. Do you see where I'm going here? Okay, so I do want to talk a little bit about the course for a few minutes and then we'll wrap up. So, so who is this course for? Feed the Peds is really designed for speech language pathologists and occupational therapists or graduate students in this space. New grads who feel overwhelmed by feeding. Right. You might be new to the space.

And sometimes we get Therapists who've been.

In the field for 30 years. And y' all are welcome too. Sometimes we get school based therapists or EI therapists who suddenly are getting feeding referrals. We have private practice owners wanting to expand into feeding. We've got people working in private practices. Sometimes they're the owner of the private practice, will put them through the course or help, you know, help support them financially. Maybe not fully, but part of the way. So ask your, ask your boss. And then we have also clinicians, you know, therapists working in hospital settings. And a lot of times those hospitals, by the way, guys have money aside that you can get put into place to cover the cost of this. We've had a lot of rehab facilities and you know, different hospital basically hospital based types of settings or you know, hospital similar programs who have sent us checks to cover. So I just want to like put that out there in case you're like, I wonder if they'd cover it for me. And if you have questions about that, you can email us@supporteedepeats.com because we can always give you information that you need in order to help you get that coverage. Because hey, it's a lot of CEUs and ultimately you're gonna be able to treat peat feeding patients which is good for business. So there's, you know, there's always that business side of things for your employer. Okay, so anyone who's ever said, I think this is feeding, but I'm really not sure what to do or like I think I need to assess this or I know how to assess but I'm not really sure how to treat, turn this into a treatment like you guys. This is, this is exactly who is, you know, who would benefit from Feed the Peas. So here's how it works. Okay? So we've got 12 weeks of on demand, step by step video lessons. It's one module release per week. We have real case video breakdowns of assessment and treatment. We have weekly mentor office hours following. It starts following module three. And that's where you basically can, what I want to call them, office hours are actually study clubs, not study clubs or case study review calls. My goodness, I'm all over the place. But the case study review you calls that we give you cases and then we get together and we talk about the cases after you've had access to them for a week so that we can work through them, answer any questions you have. We also can talk through anything from the modules you're going through. But you also have a private group where you can pop in at any time and connect with like hundreds of other like minded therapists. So we've got one group for our alumni, but we've got another one that happens during your course. And so you're able to pop in there and ask questions related to the modules that you're going through over the course of the 12 weeks. Um, and right now we still offer lifetime access, which is a major bonus because we have people who took this course back in 2020 that still have access to that version of the course. Um, we. Any updates that we've added to the other modules, we've gone back and given to our, you know, all of our past cohorts as well. But you get CEUs. So it's 4.05, which is 40.5 hours or 4.05 asha and aota CEUs. And let me tell you the confidence boost that comes from this. It's so cool to see, like, how much more competent and confident the SLPs and OTS are coming out of the course. So, you know, therapists tell me that Feed the Peds literally is the course that changed how they practice it. Some of, for some of them, it made them fall in love with feeding. And many just are now like, okay, I've got this. Which is so, so cool. Because my larger vision, my mission was like, let's get kids off feeding therapy wait list. And how do we do that? Oh, we do that by training more SLPs and OTs so that you all can go out and assist to actually assess and treat these kiddos. Right? Okay, so enrollment is officially open, but not for long. We only offer Feed the Peas a couple times a year. And this is the last chance that you can join in 2025. So join us. Go join hundreds of other SLPs and OTS who are saying yes to feeling confident and competent with feeding clients. If you go to www.bethe feeds.com, you can join us right now because doors are open. And if you have any questions at all, you can message me at Hallie Balkan on Instagra. You can also email us supporteadthepedes.com but here's what I want to leave you with, right? There's so many more things out there, but the thing that you need most is clarity, strategy, support and repetition. And that, my friends, is what we give you inside of Feed the Peads. I would love to be one of your mentors on this journey, and honestly, I just can't wait to see you inside. So thanks for tuning in to this episode of the Untethered Podcast. I'll be back next week with more insights, but until then, go check out the course your future feeding self will. Thank you.

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