Episode 126: The Connection Between TOTs, Pediatric Feeding Cases & OMDs

Hi and welcome to episode 126 of the Untethered Podcast. It's me, your host, Hallie Balkan. And today we are going to jump right on into talking about feeding versus OMDs. Why? Well, this comes up a lot and there is definitely a connection between tots, tethered oral tissues, pediatric feeding cases and orofacial myofunctional disorders. So let's jump in.

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 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.

Okay, so as a pediatric feeding specialist, I have definitely assessed a fair share of infants, toddlers, preschoolers, you know, birth to 5 years of age or so, who have had a combination of feeding challenges. Okay, we're talking feeding challenges, tethered oral tissues and or an orofacial myofunctional disorder because those are present at birth as well. Many people don't realize this, but they are. I've also worked with the more traditional myofunctional Therapy cases from 4 years of age through adults. And regardless of the age of the patient in front of you, a common theme that I have encountered is the lack of awareness that all three of these diagnoses. Right, feeding disorders, tethered oral tissues, orofacial myofunctional disorders are frequently present at birth, as I just told you a minute ago. Right. So in infants, we may see ankle, glass or tongue tie lead to a tongue that is tethered to the floor of the mouth like we talk about all the time on this podcast. And we know if you've been listening to me for some while that that's going to impair the range of motion. We also might know notice that the tip of the tongue may not elevate when an infant cries. The tongue may be unable to suction to the palate right to top of the mouth. It may be unable to cup around a breast or bottle nipple. That tongue needs to cup with the lateral borders the side of the tongue elevating, you know, cupping around a breast or bottle nipple to, you know, hold the fluid out. Or it may have trouble lateralizing when stimulated, which is a reflex. So how does this manifest? Well, this may manifest as a decreased flow of milk from the breast or bottle. And maybe mom will appear to have supply issues that are not actually her fault. It's that baby can't tell her body can't demand the amount of milk that it needs because it's inefficiently pulling milk from mom's body. Right. And later it can turn into a munch chewing pattern that doesn't develop into a rotary chewing pattern or a diagonal chew pattern. Especially when that tongue cannot lateralize food across molars to prep a bolus. Right. And if you're new to all this, like a food bolus is basically a combination, really gross for some people, but cool for others, like, you know, feeding geeks like me. It's a combination of your saliva and the chewed up food which creates that quote unquote food bolus or bowl of food on the center of your tongue that's ready to be swallowed. Now, as a toddler continues to consume solid foods, we also might see some single sided chewing, some large bites of food or overstuffing of the mouth, very common in a lot of our kiddos. Pocketing of food in the cheeks, tongue dumping. So that's where the tongue doesn't move, kind of like flatter in a flat position sideways. Instead the tongue flips itself on its side kind of like a dump truck and we call it dumping, where they basically flip the food off the tongue onto the molars instead of moving it over, you know, lateralizing the tongue with it remaining on the same plane. And of course, the ever discussed tongue thrust that people refer, you know, kids get referred to speaking speech pathologists all the time for tongue thrusts. Well, the tongue thrust may be pushing against or between the teeth when swallowing to create the needed negative pressure to complete a swallow. Okay, so the tongue should be up on the top of the mouth, the roof of the mouth, the palate, whatever you want to call it, it should be up there sealing off the mouth. Right? Sealing things off so that the tongue.

And the palate make contact.

It seals off that small space in order to swallow back the food that's been prepped, the food bolus. And when it can't do that, when it can't create that negative pressure, it has to find another solution. And that solution is why the tongue pushes forward against the teeth to Close off all the spaces between the teeth and or pushes between the lips to close it off. If the teeth is not, that's not good enough and not working, then the tongue will go even further and seal off the lips to again create that negative pressure needed in the mouth. Okay, but these are, this is just a few examples of what might be observed. Like yeah, there is a much longer list of symptoms, but these are some of the common ones that we discuss frequently with families, with other therapists. And so I wanted to highlight some of what we might see in this population. Now also with ankle o labia or liptai, we see a whole different list of symptoms. Okay, so this might be anything from like when you're thinking about our infants, like a shallow latch that restricts the flow of milk from breast or bottle to air aphasia, which is air aphasia, induced reflux, air, which oftentimes is. And this is when you're swallowing air during feeds, again often related to tether oral tissues. And this is frequently misdiagnosed as gastroesophageal reflux. G E R not GERD with a D on the end, but GER G E R if you want to look. That and leakage also of liquid saliva food bolus once they've moved on to solid foods, also very common. Now some infants and toddlers, you know, up through the preschool age will struggle to drink from an open or a straw cup starting at 6 months of age. Right. We all recommend, you've heard me recommend recently that we want to introduce Open Cups by 6 months of age and then a couple months later we'll introduce straw cups. We want to skip those sips. It be your 360 cups. But what if they're struggling to do this? Right? You've introduced it a whole bunch of times. You've tried trial different ways of introducing it. It's not working, it's not going well. We need to start looking at why. Let's look at the mouth, let's look at their rest posture. What do I mean by that? Look at their mouth when they're playing, not when they're eating or speaking or trying to communicate, but when they're just playing, doing a passive activity or when they're sleeping. And really we want to look at both sides, sleep and awake. What is her mouth doing? Because if they have an open mouth posture at rest, meaning the lips are not closed together, the lips are open apart, then that's a problem. We need to be talking about that. So if they have, they may have this open mouth posture at rest, they might be struggling to achieve that closed mouth posture with the lips together while awake or asleep, or when swallowing, or all of the above. And these children tend to experience an increase in illness as well due to bacteria entering intraorally as compared to being filtered through the nose. Our nose filters things, it keeps germs out. Our mouth doesn't do that. Our nose also does other things too, but that's why it's so important to nasal breathe. And again, this is not an exhaustive list. This is just some of the common symptoms we see. So yes, these lists are not exhaustive, but clearly it demonstrates the relationship between pediatric feeding disorders, tethered oral tissues and orofacial myofunctional disorders. And the way in which we assess for and treat these symptoms really differs depending on the age of the child. Neurotypical children who are 36 months of age or under are still developing their oral sensory motor feeding skills. What does this mean if you're going to treat them under the age of 36 months, arguably even under the age of 4 years of age? This is really pediatric feeding. This is not myo. I call it to call it pediatric feeding with a twist of tots and myo because we need to have this knowledge. We need to still work towards some of these goals. But this is not independent of how we treat sensory motor feeding. This is really the role, for example, of an slp, a speech language pathologist, or an occupational therapist who is trained in myo. And I say, why do I say this? Well, there's generally there's a combination of active and passive exercises or treatment approaches that we use these therapeutic interventions that we use to achieve these pediatric feeding goals. Right. So the problem is that those who are licensed to treat this population, speech language pathologists and occupational therapists, it is, we are the licensed professionals. It is in our scope and not other scopes. There are some where physical therapists may have feeding within their scope and so they may also do some feeding related activities. But typically a lot of the pts that I know are often working on postural changes and not directly working on feeding. But it really again depends where you're located. And other countries outside the US physiotherapists are directly involved in feeding. So you need to know, like where you're located, who are the professionals who can treat pediatric feeding. And the issue is that these professionals are not always trained in assessment and treatment of pediatric feeding or in tethered oral tissues and or orofacial myofunctional. Disorders that we have a problem. Right. And this is why we're working to actively change this. When searching for pediatric feeding therapists for our birth to 4 year olds, it's highly recommended that you search for a pediatric feeding therapist who has tethered oral tissue and or myofunctional therapy training as well. Your perfect unicorn has all three pediatric feeding, tethered oral tissue and orofacial myofunctional therapy training. Because as I said, I call these cases like Feeding with a twist of MYO or Feeding with a twist of Tots and myo. So we do have a directory actually for our pediatric feeding graduates. So Feed the Peds is the course that I teach and we do cover this and teach this for this population in that course for SLPs and OTs who take that course. And you can go to pediatricfeedingtherapist.com if you're looking for a therapist in your area. If you can't find one, feel free to reach out out to us and we can help connect you. But once a child is at the cognitive level, and I say cognitive level because it's not chronological age that oh, they've had a fourth birthday and here they, they're ready to go, no, they need to be functioning at least the cognitive level of a four year old, then they can generally start a traditional myofunctional therapy program with an SLP and ot, a registered dental hygienist or a dentist. And that said, this is where differential diagnosis is extremely important. Right. It is the job of the receiving provider to ask the right questions, determine if a traditional myofunctional therapy program is the next best and most appropriate approach. Why do I say that? Well, we could have an individual with apraxia who is cognitively functioning the level of a four year old, but they really need an slp. They need somebody who works with oral apraxia, possibly ots. But typically it's going to be your SLP who's also trained in myo, because that's going to require a very. I mean, MYO is individualized, but this is going to be a much higher level of individualization that really needs to be tackled by somebody who can treat both. It looks very different if you have a patient who has cerebral palsy. That may also be the case. So, you know, and there could be many other diagnoses that we really need to work with a professional who is trained in working with that individual and their diagnosis in addition to the orofacial myofunctional disorder. And feeding challenges that this individual is experiencing. Otherwise, we are doing a major disservice to these, these pediatric patients. Now, what else can I tell you? So we can all agree that correcting the oral rest, posture, oral prep, oral face swallow plus nasal breathing and habit elimination are all up there on the charts of important skills to teach at a young age, right? But the success with a MILE program also depends on various factors, as I just explained, you know, and I'm not going to repeat it, but as we just went over and so like when in doubt, I want you to contact your colleagues and co treat across specialties. Right? So for example, a registered dental hygienist may treat a four year old with an OMD through a traditional MYO approach and then refer to an slp, a speech pathologist, to take over when it's time to address any residual speech goals or if the feeding goals go beyond prepping the bolus. Okay? And it is the job of the receiving provider to always put patients first and provide them with the best therapeutic approach for their medical needs. Right? Team approaches are always the best approach and they get our patients the most effective results in their journey toward optimal health, which is what I preach all the time on this podcast. So we really need to make sure that we are not trying to be the do it all person for or the jack of all trades person for that patient, especially if certain things are out of our scope. And you don't want to just trust every provider out there because there are a lot of people, unfortunately that work extremely out of scope in this space who say they treat children who are under the age of four cognitively, who treat children with multiple diagnoses who are medically complex. And truth be told, this is a, it's both illegal and it's also a major disservice to the patient and the patient's family. So I share this because I caution individuals to know who you're working with, to do your due diligence and to work with the provider who is licensed in the therapy or the therapeutic approach that you are looking to engage in for your child. Now, all in all, it's important to remember that toddlers are all are still developing their oral sensory motor feeding skills until at least 36 months of age. Right? So it's critical to understand there that there exists an absolute connection between peat feeding tots and myo. But these pediatric cases require a pediatric feeding with a twist in MYO approach under the care of a pediatric feeding therapist with feeding and Ideally tots and myo experience right your SLPs or OTS. So I just wanted to highlight this and really help delineate who to contact because I get asked at least once or twice a day on social media, like which professional? I'm so confused, like what professional should I contact for this? Or who do I talk to about that? And I figured it would be really great to just hop on here and give you all the rundown so you understand who you want to seek out and why. And again, you can go to pediatricfeedingtherapist.com, which is where we are Feed the Peds Grads add themselves after they've graduated. We've had over 900 speech language pathologists and occupational therapists go through the program. They are not just all over the US and Canada, but they're actually spread across the world. We've got individuals in Europe, in Colombia, in Australia. I'm trying to think of where else we have, you know, besides Canada and the U.S. but we have a good number of individuals pretty spread out now that we have over 900 and we're about to Doors are open right now. If you're listening to this live August 30th through September 3rd at midnight Eastern time, go to FeedThePedes.com and join us. Because we know we're going to have well over a thousand of you as soon as this cohort cohort graduates in 12 weeks. So if you have any questions at all, you can always email us@supporteedthepedes.com if you have questions about Feed the Peds the course. Otherwise, go to FeedThePedes.com and join us. If you're a parent again or a provider looking to find one of these unicorn providers who have experience in all three realms, go to pediatricfeeding therapist.com thanks.

For listening to this podcast. If you want to hear more of these Myots, Airway and Feeding related episodes.

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