Episode 115: The OT & IBCLC Fusion with Sipporah Tracer, MS OTR/L, IBCLC

Hi and welcome to episode 115 of the Untethered Podcast. Today we have Sapora Tracer joining us. Sapora is a pediatric occupational therapist and International Board Certified Lactation Consultant practicing in Bergen County, New Jersey. Sappora received her Master's in Occupational Therapy from Columbia University and has been practicing in pediatrics for over a decade. She's more recently become an IBCLC and opened her own practice using the two professions for a unique scope assisting mother baby dyads with their feeding challenges. Sapora has a diverse pediatric OT background, from early intervention to outpatient sensory gyms to school settings when working with infants. As both an OT and ibclc, Sapora uses her specialty in sensory integration, primitive reflex integration, both RMT and MNRI methods, as well as Infant Oral Motor Neuroreeducation, NDT and TMR to treat the whole body as it relates to development and feeding. Peer education and team collaboration are a core part of her practice. Aside from her private practice, Sapora teaches breastfeeding classes and runs monthly breastfeeding support groups. She also runs a free breastfeeding lending library for mothers in need of breast pumps and other breastfeeding related supplies. She and her husband live in Teaneck, New Jersey have four kids ages 1 to 10 who have served as an inspiration in real life training for her work. Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host Hallie Balkan. I'm a certified orofacial myologist, feeding specialist and mentor. This 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, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. Sapora, thank you so much for joining me on the podcast today.

Thank you so much for having me.

I'm excited to chat about your background a bit and just learn about how you got into this line of work. So will you just start with telling us a little bit about you and how you got how your breastfeeding journey led you to where you are today?

Sure, absolutely. So I would say it started about 11 years ago. I was pregnant with my daughter Sarah and I had done a lot of research to prepare for the birth, I was prepping for a birth center hypnobirthing experience. And I think at the time, I probably spent more time researching which stroller was best than researching breastfeeding. I really didn't even think that it was something that I needed to really prepare for. I thought it would just come naturally, totally just fall into place and happen. And I was really in for quite a. Quite the rude awakening when my daughter was born. And we had really been through a lot together to make it work. And ever since then, I really kind of became like, the point person amongst my. Amongst my friends and community members who wanted to kind of get general breastfeeding advice. And I knew that it was something I always loved to do. But then when my. When my son was born seven years ago, the first thing I noticed about him, aside from how adorable and cute he was, was how restricted his tongue was. I mean, he was born with a anterior tie that was really very restrictive. And right away, I started knowing that in a couple of feeds, I was going to be in a pretty dire situation. And I remember trying to advocate for myself and get the help and asking, who can we pull from the hospital that's connected to the birth center to come do this release? And I was not getting anywhere. Within three days, I was able to take him for a release. And I had put all my eggs in that basket and had thought at the time, everything is just going to work itself out, and it's going to really be smooth sailing from there. That was my other rude awakening. And I quickly learned that he. He, because of his restriction, really had developed a completely different motor pattern than what he needed to effectively breastfeed. And I remember at the time, both an IBCLC and my pediatrician saying, I don't think this baby's really gonna breastfeed exclusively. And that was the fuel that I needed. It's like when a doctor says, I don't think your child's gonna ever walk. And I'm sitting there looking at my neurotypical baby, and I'm like, yep, I'm gonna breastfeed, and I want to make it happen. Exactly. So it was a lot of hard work. And at the time, the access to kind of the trainings and the resources that we have now, I mean, wasn't the same seven years ago. And I really had to kind of look within and dive into my own knowledge as an OT and what I knew about infant feeding and oral anatomy and motor function to be able to really work with him. And I had Been working also closely with a craniosacral therapist. And together we were really able to get him. It took us around six weeks to get him to exclusively breastfeed, but we did. And really from there I kind of thought to myself, you know, how are other parents that go through this helping their children? And that really became the path that I went on to really professionally develop myself and really help other families who are in similar situations. And then, you know, since then I had two other children and the whole process was much smoother because at that point I definitely knew what I was doing. And you really see how having that knowledge base and skill can really make all the difference in a breastfeeding relationship.

Yeah. And I think it's really amazing, you know, when we have these conversations about the fusion of a couple different spaces. Right. So we know you're an ot, but you also became an ibclc and pairing those together, whether you're an slp, IBCLC or an ot. Ibclc. I think it's, it's one of those things where, you know, I've even wondered like, should I go get some lactation credentials? Because when you work with these, these tots, baby, you know, babies or these infants, even if they don't have tether oral tissues, but they've got something going on motorically or their, you know, suck is weak, their sucks while the breath is off, you know, it's. I think it's so helpful to have that comprehensive knowledge and that collaborative viewpoint on what could actually be going on and it's not as one sided. So have you found that that's completely changed your practice, just having perspective from both?

Yeah, absolutely. So, yeah, what's really amazing and I think few people realize, so if you look at IVCLC as a profession, it's already an unbelievably unique scope of practice. You basically have a scope that treats both mother and baby, which is really unlike any other provider. You have ob, GYN and midwives who are going to primarily treat mother and then also help here and there with what's going on in the breastfeeding relationship on the baby's end. But really that's not the scope. Then you have pediatricians and their primary patient is the baby. Really the IBCLC comes in with that really combine together scope and treat both mother and baby. And what's amazing is that they are really completely interdependent on each other and cannot really be separated. And it's amazing to see that scope in and of itself. And then when you Take that already super broad scope, and then you add the OT scope to it. That's when you're really starting to see beyond, you know, the whole picture here. So without sounding too theoretical and delving into kind of a theory class here, if you just look quickly at the practice framework, which essentially is a summary of the kind of interrelated constructs that describes occupational therapy practice in general. So, you know, to sum it up, we basically look at occupations which include feeding and eating for the infant, but also the primary occupation of mothering. And then we look at the different client factors like body functions and body structures. We look at performance skills, like what motor skills. There are processing performance patterns like the routines and rituals, and then the context and environment. And that's essentially what we do as OTs within every patient that we're treating. But when you're applying it to breastfeeding, it really captures both the depth of what's going on with the mother and what's going on with the baby. There was a great article that came out in 2014 that talks about breastfeeding promotion in occupational therapy that was published in AJOT and really talking about how OTs can really contribute to breastfeeding promotion within the health and wellness population. When you really look at what we can do in terms of that scope and then combine it with tots, you really can see how the functional implications can really trickle down into each of those areas and then how we can further address that. But even like you said, without there being any restrictions, any kind of one area of what we just mentioned can impact all of the other areas. And really being able to come at it with that holistic approach is so amazing. At the very skeleton and backbone of OT is function. And so coming with that into kind of every single assessment and, you know, eval and vista that I do, it really allows me to kind of bring this broadened scope. And, you know, I think that another piece that's really important is that you definitely don't need to be an occupational therapist to be or a speech therapist to be an ibclc. I mean, that this profession has been around for a very long time and you don't necessarily need to have that. And what is interesting is that, you know, I find just very practically, I'll put on, you know, my IBCLC hat when I. When I come into a visit that I get, that's just purely a lactation visit. And there are very many times where I don't even need to enter that OT realm. I mean, those OT Skills help me, but it's nice to have those visits where everything is actually going fine and well. And if it's, you know, we're able to tweak things just with the knowledge of being an ibclc. And it's nice to have that baseline of normal as well, so that we can then know when things are also not going well and when those cases really need to fall into both OT and IBCLC world.

I love that, and I think that's such a great point, too, because, you know, being that I'm an SLP and I do infant feeding, but I do not have lactation credentials, you know, I always been like, you know, of course moms always ask me and they're, you know, am I positioning baby right? And, you know, asking me. So apply questions and asking me about diet. And I'm over here going, not my scope of practice. I can help you with your infant, and I will be here as moral support. But, like, we need that IBCLC to be pulled in here too. And oftentimes they have been referred from an IBCLC because the IBCLC has gone in. They've started working with this mother infant dyad, and they're saying, hey, something more is going on here with the infant's oral anatomy beyond my scope. And, like, I really would love for you to come and work with the infant. Right? So it's. These lines get so blurry, blurred. But I always like to kind of try to draw that line back in the sand and say, hey, let's pull our IBCLC friend back in here. You know, she's gonna help us figure out what is going on, you know, with you and baby, because like you said, you can't separate the two. So even though I might be there to work with the infant, I'm not walking out of there until I know mom is getting support from another provider who can provide that for her because she's equally a partner in this breastfeeding journey and relationship. And, you know, and it's so important to me that we know that our moms feel supported and empowered and. And like you said, you know, you have the drive. You were like, oh, we are going to make this work. And I was the same way with my first daughter because I took her to an IBCLC and my peds office. And, you know, she fed okay. In that visit and every other feeding she didn't, you know, outside of the office. It's like, I always joke, like, when you take your car to the shop, right? So she But I felt unsupported. I felt like I didn't even know who to turn to at that point because I was doing toddler feeding, I wasn't doing infant feeding. And we had 13 months of very painful breastfeeding. And I was that stubborn mama who was like, oh, no, we are going to make this work. Like, it's going to happen. And I would, like, turn my face away from her to latch her because it was so painful that I did not want her to see my face. And I wanted to be able to look back at her when my face did not look like I was cringing from latching her on. Because I'm like, how psychologically impactful is that? So it was one of those things where I really have an appreciation for IBCLCs in this space who understand, you know, what mamas are going through and are able to support that infant mother diet because unfortunately, I was not supported. And so I, you know, that's also where that holistic approach and working with all and any providers who are necessary for, you know, the support or for the success of that breastfeeding relationship is so critical and so crucial. And I love talking about this because it's just not something that I knew about, even as a SLP in the feeding world, working with little kids. Like, how did I not know about this? You know, it's like, I went and had a baby, and like you said, you spent your time looking at strollers. And I was like, ooh, strollers and nursery and cribs and probably should have been spending a little bit more time. I did the hospital class on, you know, breastfeeding. But aside from, like, it was more so, like, oh, we just got to do this because they're making us do this, not because I realized the importance of how this may not go beautifully as planned. And I didn't know people struggled with breastfeeding before that. I mean, I had no clue that it wasn't just this natural phenomenon that everybody flies through with, like, you know, no bumps in the road.

Exactly, Exactly. Now we are right. I remember my mom used to tell me, you know, I breastfed you until you were two years old, and I didn't have problems. And that was really what I was coming into this whole, you know, relationship thinking, oh, well, it's just going to be the same way. Yeah, yeah.

So let's talk about, like, the complexities. Right? Those shades of gray as I know you reference it for our tots babies and intervention when it comes to tots.

Yeah, absolutely. This is a Topic I feel so passionately about. You know, I think in general, practitioners, parents, we don't feel comfortable sitting with shades of gray. I think we like. In general, we like things to be super clear, black and white. This is a.

Somebody give me an answer.

Give me the answer right now. Tell me what to fix the problem.

Yes. Yes. Just fix the problem and we'll be on our way.

Yep.

So easy.

Yes. And so that's really where this idea of the functional assessment comes in. I mean, there are a lot of signs and symptoms that can sound like they are, you know, tethered oral tissues. And then when you're actually assessing them, they. It's much more complex. It's really maybe one piece of the puzzle, and then there are so much else going on. And so really, again, being able to have this scope, to do this in depth assessment, I mean, my. My appointments are sometimes three hours long. I mean, it's like, it's really crazy. But in order to really get to all of those pieces, you have to be that, you know, thorough and, you know, without really looking specifically at some of the other issues that are going on. We don't necessarily have all of the pieces of the puzzle laid out in front of us. And so, you know, I hear this. I haven't actually experienced this, but I hear, you know, some colleagues have told me that, you know, they've been to, like, a breastfeeding group, and they've heard the leader, you know, listen to the mom's problems and be like, oh, and you have a tongue tie, and you have a tongue tie. Kind of like it's like the. Like in the Oprah Winfrey show, and she's giving out cars, and you get a car, and you get a car, and. And that actually really steers this issue towards a fad. And really, when you're working in this space, you have to make sure that that's not where this goes, because there's a lot of. It's a lot of danger. There's a lot of hysteria, as, you know, anxious parents who are just trying to do right by their children and just trying to solve problems. But I think that when we don't actually evaluate whether a frenulum is restrictive or problematic, we don't actually know. And I think that that's something like a message that's just to send that we really have to not only look at the oral potential restriction, but just the oral function in general. How is that baby moving their tongue? How are they moving within their mouth? What is the jaw strength like all of these different various factors, and how is that baby doing all those things paired with the mother's anatomy and the mother's supply. Right. Because that is going to look so different. And so really, at the end of the day, you just end up getting such an individualized picture of what's going on, which really is not going to be the same across any other dyad. It's like fingerprints. Each one really becomes very unique because of these multiple factors that we look at at the same time. So I think that that's, you know, that basically sets the foundation for why there are these shades of gray. And then the question is kind of like, what we do? And so, you know, you and I are both therapists. We're not surgeons. So. So the first thing we're going to do is try to intervene with therapy and try to improve function. And so, you know, I think that that's. That's an amazing thing. Like, if we're able to improve function with what we're able to do, then we can all go home and sleep well. And, you know, that's. That's what we're into this for.

Yeah, no, and I think that's a really great point because, you know, everyone always says to me, well, how much therapy do we need before release? Or how much this or how much that? And like you've said, there's a blueprint here that's individual, not blueprint, but there's a fingerprint here, right? There is. It's so individualized. And it depends on that dyad who. You know, mom could have her own maternal health issues going on that are impacting breastfeeding. Baby could have other things going on that it might be missed by other providers that could be impacting breastfeeding that could be impacting, you know, how awake they are, how alert they are, or it just. There's so many factors. I mean, we could sit here and list them off all day long, and we ask about these things on our intake. We ask about these things in our assessments. Even though we are not lactation and we do not assess lactate, you know, we are not assessing fully. We are screening. We are trying to ask questions so that we can determine, is it going to be enough that you start with us, or do we need to immediately refer you out to another provider who can better serve you and. Or work alongside us right now? Like, what does that look like for you? Because there are no two treatment plans that look exactly the same. Like, we might be all working towards the end goal of, like, let's get this baby feeding optimally, you know, maximizing their ability to breastfeed or whatever that goal is for that mother infant dyad, whether it's breast bottle or a combination of the two. But the way that we get there, the providers involved, how much therapy is needed between each provider is so highly individualized that it drives me insane. And you see me making these comments on social media about we can't diagnose from a picture. And it's not just that I'm trying to recycle that comment from other people in our professions who are constantly saying the same thing. It's that we are trying to educate. Because a tongue may appear tethered in a photo, but when you actually work on function, you can sometimes get that tongue very functional. And maybe we monitor at that point because if a baby's feeding well, we don't want to interfere with that. But if the baby hits a roadblock where they stop feeding, well, well, maybe that changes the intervention plan, right? Maybe that, that, you know, and sometimes we can get these infants feeding really well at breast and not me, but my IBCLC along with us working in the infant's mouth, you know, and then they introduce solids and everything falls apart. I am not pro release baby now because something might happen later. I am, let's make sure baby is healthy, optimize their ability to feed, optimize, maximize whatever term you want to use and make sure that mom is happy and comfortable and that this is a successful breastfeeding dyad. Because also the goals that I, and this is what I've learned, even though I'm not that IBCLC and I don't have lactation credentials, every mom's goal is different and what breastfeeding looks like to them is different than the next mom's breastfeeding goals. And it's just been, it's been opened my eyes working with these mother infant dyads to the fact that, you know, a new provider might walk in and go like, well, you just want your baby to breastfeed. Well, no, maybe this mom doesn't want to triple feed because that's going to put her over the edge. Maybe this mom does not want to use a nipple shield anymore. She's really trying to wean off of that and someone else told her that she's going to have to use it for her entire breastfeeding journey. And you know, so what their specific goal looks like is always different. And it also impacts what I might do with the infant because, you know, and working alongside the ibclc, we're trying to work together to achieve this dyad's goals. So, you know, it's a, it's definitely a long conversation and road we could go down even further. But for all intents and purposes, I mean, I think we have to understand that, you know, we can't push our goals right on.

Right.

Dyads, we need to understand where they're coming from. And we also need to understand that sending a baby for a release, if they're feeding well, could actually tip us the other direction and cause a heck of a lot of issues and a lot more unnecessary therapy that's going to become necessary because we went in, we released and this baby wasn't ready for it and, or maybe they didn't necessarily need that right now. So anyhow, 100%.

No, I think you brought up such excellent points and I just want to completely agree with you on that and also just come back to that real individualized care and that, that there isn't one size fits all. And then, you know, I see this a lot, especially in the aftercare world, the YouTube videos with these kind of stuck training protocols. I really, I cringe, I cringe because it's, it's really like, you know, a shot in the dark. You're kind of just like throwing, you know, something at the wall and hoping it sticks. Yeah. And sometimes, you know, babies can benefit from some of the aspects of that there are in these videos, but they're not individualized at all. And behind every intervention there has to be a very clear therapeutic rationale that's individualized for the patient. And if it's not there, then you shouldn't be doing it. And I am always very self critical. I will constantly be trying to improve myself and strive for learning more. And the day I stop learning is the day I stop growing. And that's, I think, an important piece because I'm always happy to learn something else and something new and more. And I think that that kind of self reflection and being critical really makes you need to be thoughtful and have that very clear therapeutic rationale behind what you're doing. And I think that the other piece of what you said that really resonates with me is really being a realist. I mean, we really, we have to in this space be both compassionate and realistic to what the parents are going through. And really unless you've been through it yourself, you really don't realize that first of all, your words have a lot of weight and your treatment plan has a lot of weight and if we are going to give these, you know, intensive treatment plans or start to kind of take parents down this road, that might not be necessary. I mean, what is that really doing? It's having a frenatomy. Like, it really needs to be very calculated decision with a team and with a very, very clear functional lacking that's present that we really are trying to improve on very specific functional goals for. And so I think that all these really important pieces and really understanding that the complexity of this and not kind of being a quick trigger like this is one and done, and let's move on because without really knowing what you're going to get yourself into, this could. This really could send parents over the edge.

Yeah.

Yeah.

And really, you know, I think that's a really great point too, because maternal health is something that we don't talk enough about. We've. I've had some amazing guests on the podcast in the past who are OTs, who are, you know, who have been moms who have breastfed themselves, you know, SLPs. And we've really gotten into talking about how, like you said, like, we go into this like, I'm going to have a baby and I don't know what. I don't know what to expect. I know I don't know what I'm doing. And then you come out into that fourth trimester and your hormones are all over the place, and there just is, at least in the US there isn't enough support for moms from a mental health standpoint right now we throw an issue into the mix. Now we've got a baby who can't feed, and now mom feels guilty. Mom feels like she's failing her child. Because what is your one job? Keep your baby healthy, happy and alive. Right. And if we can't keep that baby fed, then it starts to feel like a reflection on us as moms. And as much as we know that on the other side of it, maybe that maybe, you know, to people who either haven't had children yet or to others who maybe have not been through this experience, it might sound like, oh, well, come on. Like, you can't blame yourself for that. But that's just what happens. And that's the reality of where a lot of these mamas are. And to see them in my office in tears because they are failing their. They're failing at their one job that they felt like they were going to succeed at. And it's this rude awakening that, oh, my gosh, we have. We've got quite a thing to work on right here. And this is not easy. This is hard. And why didn't anybody prepare me for this? Why are you the first person who's telling me that, you know, X, Y and Z may be going on or that maybe I need to talk to this other provider? Like, you're the fifth person I've talked to already, and nobody has been able to help me. Or, you know, we get so many different scenarios, and I think the one thing we have to be so cautious and cognizant of is, you know, there's this fine balance between educating parents and respecting their wishes as well. Because that mama baby saying to you, without saying to you, like, this is all I can handle right now. Like, I'm good with the nipple shield. Like, if that makes us successful, that's what I. That's all I'm willing to do. I'm not willing to do those triple feeds and pass zero judgment, because that is that mother's decision. Right. And it's, you know, it's so interesting to me, too, because, you know, we just see so many different cultures play into this, and sometimes mom is not always the person making all the decisions, even though it's her body and she's the one feeding the baby, you know, if she's breastfeeding. And, you know, there's just so many layers to this onion. It's not a straightforward thing. And I think that the way that it gets thrown around and the way that it gets treated, in a sense, and the way that some people are even teaching it out there really starts to beg, you know, who's in charge here? Not meaning, you know, meaning, like, are we in charge as the providers or is the parent in charge? Because really, the parent should be driving the bus here with us as clinicians, guiding them and making sure that they're fully educated and then allowing them to have informed consent. Like, what do you want out of this? What is your goal? And am I doing everything in my power to help you achieve your goal?

Yes, exactly. Exactly. That. Really, the first thing that we need to always do is, what is your goal? And how can we support you? And if we go in with that frame of reference, then we're. Oh, that needs to always be the guiding frame of reference that we're using. A hundred percent.

Yeah. And it's as simple as asking that on your intake. On our intake, we ask them, you know, what. What is going on? Like, what is. We want to understand from their perspective, what is the. What is your concern? What are you hoping to get out of Working together. Because when we ask them that on our intake, it gives you so much insight right into that. And then when you meet with them in person, you can dive further into that and you know, ask them like, what specifically do you mean by X? What specifically do you, you know, please like share with me your journey thus far. When you ask a mother to share the journey, you also learn about birth trauma. You learn about what they went through during, you know, their pregnancy. Do you learn about what maybe it took to get pregnant? And some of these moms, I mean, this is so deeply rooted. It's not always just about getting baby to breast. Right. And so, you know, when you work in this realm, like that's, that's it fuels me like to talk about these things because like you said, when you see these suck training programs just plopped onto YouTube, like it is so far removed from the reality of what we do in our infant feeding sessions and our breath. You know, I'm sure with, as an ibclc, you know, in your mom dyad sessions, that, yeah, it's.

Yeah. And that's really also, you know, part of why these visits are so long is because mom sharing the journey is therapeutic in and of itself and really also helps mom shape what she feels. I mean, you know, if you're going into a postpartum dyad, that's really very close to being postpartum sometimes. Mom hasn't even stopped to think for five seconds since she gave birth. And so really being there and creating the space for her to process really allows her to really also understand and explore what her goals are. And sometimes mom doesn't even know what her goals are and she just wants to take it day by day and that's okay too. And wherever the dyad is, that's where we need to, to really support them where they are on that continuum. Yeah.

And I love that. And it just made me think back to like the weeks after giving birth where I was like, I had a child who wasn't feeding and I was like, I can barely walk, you know, let alone try and feed my child. And it's not working. Nothing's working. This is like I have to take care of myself. I have to take care of this screaming baby. You know, it's. Moms are going through a lot and I think we all kind of need to take a step back and really appreciate and recognize that because that's, that definitely plays into our treatment.

And it's also not so simple sometimes. I'll hear this from well intentioned pediatricians that are trying to preserve and look out for maternal mental health with really the best intentions. And they'll say it's okay if you just give up or give formula. And if a mom is really ready to move to a different feeding method, we will be there and we will support her with that decision and we will process it. But what I do find is that sometimes, even though that was said to really kind of help mom, it actually creates more mom guilt. And it really actually then sends mom into. I've seen it send mom into years of therapy for herself to try to process, you know, what happened and that loss when, you know, maybe actually instead of just giving up, really referring out to someone who can really look in depth instead of just saying, okay, so, you know, you don't have to make it work, but without first trying to give the support and the resources that could have actually helped her when she wanted to be successful. Yeah.

Oh, yeah. I mean, if I could read through all of the lists of things that pediatricians have said, and I always say we love our pediatricians, we need our pediatricians. And I do really appreciate mine. Mine would do. And I don't know that all do this, so that's why I'm sharing this. Mine would ask, you know, and have us fill out maternal health screeners as well. Every time I did my infant, my child's, you know, screeners or any questionnaires before going in for the appointment, they were always screening for, you know, maternal mental health concerns and really wanting to make sure that mom felt like she was in a good place, you know, So I really appreciated that because I know that's not common. I know that some pediatricians might do that, but I felt like, you know, okay, they actually really do care about both of us, which, you know, is that their job? Is that not their job? Like, really, they're a pediatrician, they're here for my child. But the fact that we know OB GYNs, like, they're not sending me those screeners. They're. They're seeing me six weeks post op and I had complications with my first, and I still didn't get seen until six weeks post op. But I was taking my daughter into the pediatrician the day we got home from the hospital for weight checks and, you know, seeing them a heck of a lot more. So there isn't this of kind clear delineation of who's supposed to really take over what in the U.S. you know, when post, you know, postpartum. And I really think some work needs to be Done there too.

Oh, my gosh, yes. Yes. I, I've been trying on a grassroots level, really trying to work with some of these obs that I just, you know, grew up with and I'm friends with to try to change the system. But I mean, this is taking on a huge project, but absolutely. The system, the system has to change. We need to have, you know, basically, if you think about it for a moment, as a pregnant mother, you are being cared for so intensely at the end with such close contact with your either midwife or OB that the frequency of the visits just increase. We are basically there. You can be there every couple of days at the end and then all of a sudden it's like, you drop the ball. It's like, okay, bye, we're handing you out. Pop the baby out.

You're good, you're good.

And you're like, what?

What just happened? Yeah.

Yes. And where do I go from here? And I really think that actually what I see being the most successful, honestly are the patients that reach out to me for the breastfeeding information and classes prior to giving birth. Those cases always seem to work out really just so smoothly because they have that education and then they have my number saved, you know, in their contacts calling me at the hospital. You know, this is what's going on and it just, we're able to intervene really early and get what needs to be, you know, done and really help the situation right away so that, you know, we don't have any of these other secondary issues or nothing. Spirals, you know, out of control.

Yeah. And I mean, I will say I would have never known to call an IBCLC if they, if my hospital did not have them on staff. If they, you know, they basically offer it to any mom who's interested. They don't push it on you. But it's a very mother baby friendly hospital. You know, they're recognized across the nation for room, they room in, they don't give you pacifiers, they won't push a bottle. They really are probably breastfeeding, all that stuff. And I appreciated that because it's a traditional hospital in every other way, shape and form. And so I did have the IVCLCs come in and try to help and they were great. But again, gag orders, like they could not talk about anything. They couldn't go in the baby's mouth even if they're trained to, you know, And I thought that was so fascinating too, because I didn't know as a new mom, even as a feeding therapist, I had no clue Until I later discovered why things were the way they were. That did drive me to asking my pediatrician who then said, we have an IBCLC on staff. And I tried to work with them and you know, it. That was not actually super helpful to me. And I ended up just kind of foregoing it myself. She was released at 24 months after we had were weight. You know, we're long done with breastfeeding. But, you know, it was at least it was something. And you know, I've learned that other countries have these, these individuals in place and I know they're like called different names in different countries or have different. Not names, but different titles, I should say, or professional titles that go in and support mom and it's covered by the government. It's something that every mom receives some care and the focus is really truly on mom because mom needs that support post birth. It's just we're lacking so much.

Yes, I know on a daily basis I reference, I'll always try to help moms take a step back from where we are in the US and really look at other countries and just draw examples for how a lot of other countries are just doing this so much better. Like what are we doing wrong? Insurance.

Insurance.

Yeah, you're right. That's what it is.

Yep. One word sums it all up, unfortunately, you know, and then it really comes down to who can afford to pay out of pocket for the help that they need, which is really a sad reality and not, I think, you know, hopefully, because this is not something that I've really jumped on. I don't think I have the time or the bandwidth to do it. But if someone's listening and you're passionate about this, get out there with some grassroots efforts and, you know, and advocate and let's see, can we get something going? Because postpartum mamas need support. And so many babies would be, like you said, the moms who have this before they give birth know as soon as baby is born, maybe what to look for or at least to recognize if something is not going as planned sooner so they can get the help they need sooner, which early intervention, like even though they're within the first year, those babies who get help early on in the earlier weeks of, you know, following birth, like those babies typically, unless they have a lot of other medical complexities like those babies typically are, they just do so much better. We see such amazing results and you know, the earlier we can get in there, the better. So anyways, will you talk to us about some other methods, methodologies, out there that are used to help breastfeeding. You know, I'm not the breastfeeding expert, so if you could share some of that with us, I would be so grateful.

Yeah, yeah, absolutely. So I can kind of talk about some of the other techniques that I really bring as an OT to in this kind of fused perspective that I have. So I'll use a lot of reflex integration. So there are a couple of different kind of methods out there for reflex integration. There's rmt, rhythmic movement training is one of the big ones out there. And then there's mnri, which is the Maskitova neurosensory motor reflex integration technique. And so I'm trained in both of them and really helping, really that knowledge helps to be able to tap into some of the inborn automatic mechanisms that are in place to help with feeding and also help to knowing that having that knowledge also helps to be able to assist in situations where the reflex might be negatively impacting the breastfeeding relationship. So I'm happy to give a couple of examples. So, you know, sometimes I'll walk in to a consult and I'll see that the baby has a very overactive moral reflex and is really in that heightened fight or fight response. And you're not really going to feed well when you're in that response. And so there are, you know, simple techniques that we can do to be able to help kind of calm the nervous system prior to feeding. Another example of where we can have kind of some of the reflexes get in the way is if you have the asymmetrical tonic neck reflex based on positioning really can sometimes impact how the baby's able to latch. So really showing mom, you know, why it's important to have a neutral position and kind of having the baby set up position wise in a way that's going to be successful is important. Can also help with the baby latch. Then really understanding some of the reflexes that we can tap into for increased gait response is very helpful. You know, there's like this Babkin reflex that you can press into the palms and then have a jaw widening. And that's something that's really helpful also. Well, I'll kind of use that. Although parents will often moms will say, where's my third hand? Where's my fourth hand? How are we doing all of this? So yeah, I get that also. But kind of being able to use the reflex perspective to help is one piece of it. Some of the other techniques that I use really are surrounding with one way we're finding body tension in torticollis, and that's really helpful for feeding, you know, some really understanding how torticollis works and this. I also have lots of personal experience with my own kids. You know, we don't like to use feeding as a time to stretch in general. Like, the treatment of torticollitis very much moves past this kind of passive stretching and very harsh stretching and really, you know, move towards more actual movement and kind of, you know, releasing tension through movement and active ranges. And so really understanding that when you're breastfeeding a baby with torticollis, that and understanding really mapping out their actual restriction pattern, you can then see, okay, well, how do we position this baby so that they're going to feed in comfort? Because as a baby feeds in comfort, they're much more likely to release the tension than if they're trying to feed, you know, while their muscles of their neck, which is of course impacting the muscles of the tongue, you know, are all impacted. And then the feeding is really compromised. Yeah. So those are some, you know, a few techniques. And then, you know, with my background, sensory integration, that really helps to be able to read the nervous system of the baby. And a lot of times we can try to be creative with, you know, how we can also add other sensory techniques, whether it's either like a rhythmic vestibular movement while the baby's feeding. If again, their nervous system is on high alert, we can add that to help, again, assist the baby in those feeding behaviors and really optimize their function for feeding.

That's amazing. And that's where it's so cool to see a provider like yourself where you have these various areas that come together so beautifully because it's, you know, you made so many good points and I've, I've learned about some of this stuff. I'm not trained in any of this, like, formally, you know, formally trained, but I've taken infant feeding courses where some of this has been touched on and, and I'm able to recognize when some of these things are happening and refer out. Right. Bring in somebody who is able to work with mom and baby on positioning and understanding, you know, what the fascial restrictions look like, where, like, what are the, you know, what are the patterns? Map them out, like you said. And it's so fascinating to me, too, because my, my second one was released at five days old and I did a lot of work with her, and then we went into PT and she was that baby who definitely had a side preference, like, you Know, and that, you know, and both my kids could, like, hold their heads up at birth, which I knew was like, like, okay, we're a little tight here. My second one, though, like, dragged her right leg behind her and never truly crawled until. And we went through a bunch of PT and it kept her on track so she didn't fall behind. And that was kind of our goal at the time. But it wasn't until I got her in. In with an A CST and then like, about 10, 10 days later, after we felt like that was integrated and okay, like, we. Then I took her to an osteopath, and right after that, she, like, got up and started walking and then like a week later started crawling. I don't. I don't remember the timeline. Like, Sometimes I say 10 days, seven days. I don't know. It's mush in my. But the bottom line is, like, pretty soon after she saw these providers, she finally got up and walked and then within the week started crawling across the couch. And I was just talking to somebody else about this. It's probably going to be like, on the episode right before this one where it was. She was a CST and we were talking about also an OT and cst and we were talking about, like, just the, you know, how excited I was that my baby, who can now walk was now crawling. And my husband was like, why do you care? She can walk? And I was like, no, you don't understand the gravity of the situation. Like, things are integrating. Like, this is just. She's experiencing the world in a different way and this is so important. And we can't skip crawling. Okay, so.

Exactly. Yes, I know. I get that question all the time. Skipping, crawling.

Nope, nope. We don't want to skip it. No. And it was. It was really cool, though, to see because for all intents and purposes, you know, I think the therapies and the things that we deal with are all helped, but I think that that CFC and. Or Osteo and our combination really helped to actually, in a sense, like, unlock her body. So all of the work that we had done with the PT then became helpful for her. Like, we had kind of primed the pump, so to speak, but she wasn't fully realizing the gains of it because we weren't looking at it from another perspective and really looking at the fascia. And, you know, and traditionally in PT they tend to work against the fascia. Fascial restriction. Whereas, like, the CST and Osteo were kind of going with the restriction, you know, kind of working in. Towards it and in order to release it. And that's really what I think really made it click and stick for her, because she was the kiddo where, like, no matter what you try, like, I just tried to do my homework, and it just. She was fighting it. It wasn't comfortable for her. And it just made me think back to, you know, these kiddos, they. They feed better in certain positions based on what's comfortable. And we also, you know, I always like to say, like, we only have so many energy buckets, and if we, you know, if we're in pain, there goes maybe 1, 2, or 3 of our 10 energy buckets. Like, boop. Automatically disappears. Right? Now we got seven left, and if we only have seven left, and now there's a tightness, we can't even, you know, reach the breast properly to even. Even if we do have a full gait, like, well, that's. That's a problem. There goes another energy bucket. And, you know, you keep knocking out these energy buckets, and pretty soon you realize we don't have the full 10 energy buckets that we need for a successful feed.

Right.

And it's just something I like to use visually with parents to explain to them, like, you know, we do best when we feel our best. If we don't feel well, we don't want to eat, we don't want to work harder. Our energy has been expended elsewhere, which is also the same that we see when babies, like, make leaps. Sometimes if all their energy is focused on one area in typical development, we may see them put another area of development on pause slightly while work through something that, you know, they're gaining right now. And so there's just like, sleep. Exactly.

We've been there. We've all been there.

Oh, yes. I mean, it's just. It's so complex. And I think it's really awesome that you've got, like, the ot, the IBCLC background, plus these other methodologies to really help you. I mean, like, what a powerhouse. Like, so cool.

Thank you. Thank you. Yeah, yeah, it's really cool. And, you know, it's kind of funny because, again, like, we're all kind of helping within our own scope. And like, I had the other day, I was speaking to a pediatrician, and I was, you know, gently trying to kind of guide the parents and the pediatrician, just that, you know, it would be helpful that maybe the baby could really benefit from a couple of sessions of therapy. And the. And the pediatrician was like, no, I think just the Parents are anxious. I don't think the baby needs therapy. And then the next day, the mom called me, and apparently the pediatrician had prescribed reflux medication. And so this is actually.

Scream. I want to scream.

Right. So, like, we all are just trying. And I'm not upset. Like, I, you know, at this point, it's like, it's ironic, and it's almost like it's funny. Not funny. Right? Yeah, we're all just trying to help within the scope and within the abilities that we have. And so for, you know, the pediatrician, that's medicine, you know, and then being able to prescribe medicine is how they're able to help. But, you know, it's funny because it is sometimes hard to kind of explain the value of therapy in that space, you know, for feeding. And, you know, I have, like, a wide range of, you know, patient population, so, like, I'll. I happen to have a lot of SLPs and OTs and IBCLCs that, you know, bring their kids because they kind of understand how. How this works. And, you know, that kind of process goes much quicker. And then, you know, you have parents who, you know, don't even know where to begin and where any of this starts. And that really is like, again, like you said before, kind of what we say in bits and pieces and. And what the parents are able to hear. And really, that's when you start using that therapeutic use of self to really say, okay, what does the parent, you know, need to hear right now? And what are they able to process? Because, you know, overwhelming them is also not, you know, the best case. And sometimes we don't get it 100%. Right. And, you know, because we're humans still. Yep, exactly. It's really that balance of, you know, not wanting to, you know, say too much, but also just kind of help guide very slowly and with those baby steps.

Yeah, absolutely. And I mean, I think that's where like, the whole parent education piece comes in, because I really, truly feel like it is our job to encourage these parents to give them some ammunition, if you will, to go back to other providers and ask questions, especially if their baby's been put on medication. Like, why are we resorting to medication? I know that's what we, you know, to do right now, but why not refer out for something behavioral before we put a chemical in this baby's body? You know, it's just. It's one of those things where if we haven't exhausted our other options. Right. We should not be jumping straight to medication. But unfortunately, again, Insurance and the system that we live in in the US tends to prescribe medication over the, you know, behavioral therapeutic type of interventions. Oftentimes it's a prehab rehab type of therapy that gets referred for if there's a surgery that's going to occur, whether it's a frenectomy, frenatomy, or we're talking some other type of surgery, you know, versus, well, hey, let's try to avoid medication. And I respect our pediatricians because at the same time they may be looking at our, at the parents and going, you know what? This mom is on, like her last, like this is the last string. And I really want to help save this breastfeeding relationship. So I'm going to prescribe these reflux meds because if this helps, baby and mom can get baby back to breast and they can both get, you know, a couple hours of sleep between feeds. Like, I think everyone's just going to be happier and happier and healthier. And I'm not knocking the pediatricians for that, but I am knocking them for not being open to having conversations and not referring out when they've become educated on the other options that are out there. But, you know, it's. It's not that black and white or that straightforward, unfortunately.

Exactly. Yeah. And I mean, that's amazing that, you know, you're even able to see the complexity and trying to take perspective from what, you know, the pediatrician's, you know, you know, medical rationale or clinical reasoning is. And I think that that's. That's amazing. I wish, you know, everybody could be in that same thought process and trying to really see all the perspectives on this.

Yeah. I mean, at the end of the day, like, you know, we know our physicians all sign take an oath to do no harm. So do I think they're trying to bring harm to these babies or moms? No, I really don't think that. And I think that's also why as parents, we tend to put so much trust in our pediatricians and in our MDs in general, because we know how much schooling they've gone through. We know that they have a really high level of knowledge. It's just very. It's frustrating sometimes when you're working in our field. Right. When you're dealing with these babies and we're going, okay, but we have done all the extra education, we've gone down the rabbit hole of truly understanding how to therapeutically help these babies and these moms. And it really puts a crimp in our plan when you just Throw them on some meds. Because now we also got to wean a baby off these meds when we realize that they're not working.

Right, right, exactly.

It's, you know, really. And again, at the end of the day, I think, you know, you had mentioned something about like that parent education piece. Our goal is to help bring confidence to these parents in helping them believe and truly achieve whatever goal that parents sets out to achieve for their, you know, their feeding desires, whether it's breast bottle combination, like whatever that parent's goal is. I think it's really our job as providers to be cheerleaders to some extent and say, hey, like, here's what I can do to help you based on what your goals are. Let's work together. Does this, does this sound good to you? And really, truly link arms and try to be that, that, you know, rah, rah support system from, you know, using our specialty knowledge that we have. Because, you know, it's just, I think that's also lacking and I think parents feel like they're really on an island even when they do go to some of these providers out there.

Yes, 100%. Yeah. And sometimes parents need to even just sit and digest and then call back to process. I get that a lot. And yeah. But you know, it's really important to me that parents really feel both, you know, confident and competent in what, in the therapeutic exercises that they're going to be carrying out. And you know, especially if we do determin, you know, together as a team that, let's say a baby does need a frenatomy. I, you know, basically make parents teach back after care before they even have, you know, when I'm lucky enough to get a baby beforehand, I have a lot disproportionate amounts of babies that come afterwards when, you know, things are not working out the way they had initially planned. But when I am lucky enough to get a baby beforehand. And really having parents learn wound care when they're not in a state of flight or fight themselves, it's like trying to learn the Heimlich maneuver when someone's choking. Your brain is just not able to process new information at that time. We know in general studying the way that people learn and you have to be in the right state of mind to be able to absorb information and learn it. So having parents when everything is calm and the baby's not crying and the baby didn't just go through a procedure, really show me. Okay, well, this is what I'm going to do. This is, you know, how I know that I'm doing it correctly. And really showing me that teach back, I think is something that I hear later on feedback wise really helps parents know that they're doing right. And then, you know, like the worst thing, it's bad enough if a parent has to go through the process of, you know, having this procedure, but what would be worse would be if there was reattachment. Right, right. So, I mean, so, you know, this. If we can have it done once and do it right and have the parents really competent and knowing how to, you know, do the aftercare, that really, you know, helps the whole entire process.

Absolutely. And that's. We do the same thing where we make them practice on us.

We practice.

So we'll do it on them, we'll do it on the baby, we'll have them practice on baby. And if they're really struggling, we'll also have them do it on like on the provider, on us. Because, you know, oftentimes parents are like, well, am I doing this too hard? Am I going to hurt my baby? Like, is this, Am I giving enough pressure? I mean, they're not in other mouths, like, right. Know what, what it should feel like. And even if we all kind of take a step back, for those of us who have been working with infants for a while and we remember to the early days of going in an infant's mouth, it was like, I don't know what I'm feeling. Is it supposed to feel like this? And it probably wasn't until I had my hand in like a couple dozen babies mouth that I started to realize like, oh, oh, that's what the fat pad should feel like. Oh, that's where the tongue should. Okay, all right. Well, that's what the tongue feels like. And you know, discussing things like therapeutic nail length and what that means for them so they don't hurt their babies and you know, just all these different really simple things for us because it's what we do day in, day out, but scary and complex kind of things for the family unit. It's so helpful when you can get in there beforehand. And that's why I'm such a big preacher of like, you know, pre op, pre op, pre op. Because even if the baby comes in and doesn't end up needing a procedure, at least, you know, we, if they do, at least the family was in there working with us. And we've, like you said, we've been able to help them learn what they need to do post op. Because the last thing you want to be doing is getting that phone call which I know we all get too often. Like we just left the release provider's office and we were told to call you. We're going.

No.

Okay. All right, well we will help you but like already we know this would have been so much easier if you had come in beforehand. So anyways, that's a whole nother hour long conversation so.

Yes.

But if anybody wants to find you Sappora, can you share with us how they, how they find you?

Oh yeah, sure. So my website is just my name.com Sephora tracer.com also you know social media, Instagram, Facebook at lactation ot. Yeah and I'm you know in the teaneck area. I my model is really home visits primarily. I am also in birth center when needed for anyone that's too far for the home visit trip. So yeah, fantastic.

Well we will make sure that we have that all in the show notes and thank you so much. This has been amazing.

This is really fun. Thank you so much. It's so great to be in this conversation with someone so like minded. It just. Yeah, it's great. It really helps establish that community, the professional community. So thank you. Thanks for having me on.

Yeah, absolutely. Thanks for joining me. Thanks for listening to this podcast. If you want to hear more of these Myotots, Airway and feeding related episodes, be sure to leave a review on Apple podcasts or pledge a small amount on patreon.com forward/the untethered podcast. If you found value, others you know in this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook on my Facebook page page at hallebulcken Biz on Instagram at Hallebulcken and you can head over to theuntetheredpodcast.com to grab a copy of the show notes where you can also subscribe to be kept up to date on the latest podcast episodes.