Episode 127: A Myo Case Study: 5.5 Year Old

Hi and welcome to episode 127 of the Untethered Podcast. Today it's your host, Hallie Balkan and we're going to go through a case study together. A myofunctional case study on a five and a half year old. So let's jump right on 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. Hello my friends, it is your host Hallie Balkan and we will get back to having guests on the podcast more regularly. But I wanted to do some episodes for you all first where we can really dive into myo because we talk about myo, we talk about like what it looks like when we have birth to five or birth to four, like more of a feeding age. And then we also have talked about like, you know, all these different MYO scenarios and so symptoms and things that happen. But what we've never done on the podcast before is actually gone through a case study. This is something that's usually reserved for my MYO membership and it will be included in my MYO method, which is my MYO course that's coming out in mid October. And so I wanted to hop in here and I actually have a evaluation of a child five and a half year old that we are gonna talk through and we're going to discuss how they got to the practice and what the findings were and what the recommendations were. Following the orofacial myofunctional evaluation, this child, five and a half years old was referred to the practice by their speech pathologist and they wanted them to have an orofacial myofunctional evaluation. So they were referred specifically for that there were concerns about and the concerns from the speech language pathologist who referred to who did not do MYO right, but knew enough to know that we had concerns about oral rest, posture, oral face feeding skills, articulation, and that's why they referred to another SLP another speech language pathologist. So we could also look at articulation during the assessment. These were all assessed during this evaluation. Now, who can do myo? We've talked about this before. So when you're dealing with that four year old on up through adult crowd, you've got speech language pathologists, you've got registered dental hygienists, you've got occupational therapists, dentists. And then depending on what organization you're speaking with, there may be some other professionals who also are involved in actually assessing and treating myofunctional therapy. From a myofunctional therapy standpoint, obviously there's more people on the team, but that's not what I'm talking about right this second. This child was born at 39 weeks of age and in a hospital setting, weighed 8.8.4, 8.4 pounds at birth and there was loss of oxygen during delivery. They spent about 36 hours in the ICU. Now, why do we ask about these things? Well, as an slp, it's been drilled into my head that we always need to know about birth history and ideally pregnancy as well. If we can get that information. It really gives us so much information about what might be going on with a child and where some of these issues may have began. Because oftentimes children are born with an orofacial myofunctional disorder. It might not be as obvious and then it gets worse over time and we don't notice it till they're a bit older. If you're not really assessing for it or maybe they're compensating well, and then things start to fall apart at a certain age and all of a sudden they land in someone's office for a myo eval. Regardless of the case, it is very helpful to go back and get a history sometimes. We were actually discussing this recently in my MYO membership on our case study call. We were actually recommending that the patient that we were reviewing for the case study, we were discussing with the, the treating therapist that it would be interesting to see this, this adult patient's childhood photos because the, you know, well, I'm not going to go into it because I don't have permission to discuss it on the podcast. But it was just very fascinating and we were really curious what this individual looked like as a child. And so we get, we can, we can glean so much information from this. Anyhow, this child is also still pretty young, five and a half years old. So it also is just very helpful because it's, it's not that far away in their life to where they are today. Now with hearing. Their hearing is reportedly within normal limits. They did have ear tubes placed at one point and this was about three years prior to the eval. So when they were two, they had ear tubes placed. Vision was reportedly within normal limits. No known allergies. They were a nail biter, but no other habits reported. And for the most part, most motor milestone like motorist milestones, behaviors, no concerns there. Feeding also seemed to be reportedly within normal limits. The child latched at birth, Breastfed exclusively for 6 months. Weaned from the best breast around 2 years of age and a sippy cup at 3. Never took a paci. So pretty good there. No concerns. And then from a speech language standpoint, they did have an expressive language delay and received services. And so that was one component here that shifted at a certain point around 3 years of age to looking more into articulation and speech intelligibility, which is how much of what they say we understand beyond actually, you know, the articulation is how the sounds are produced, the speech intelligibility is how much of that do we understand? So this child was a little bit of a late talker and then had some articulation issues. There's no history of recurring ear infections in this case. However, they did have fluid in their ears at one point and that's why those tubes were put in. Again, that was around two years of age. And this child has made progress with other sounds in speech, but very slow. And there's still other sounds to address. So. So that's a bit about the speech language history. No medications, no dental, ortho history, family history. This child did have an adenotonsillectomy when they were about three years of age, I wanna say it was. And meaning they had the adenoids and tonsils both fully removed. And so when we go into. So that's the history. Okay, so what do we know? What do we know about the history? We know that really the main complaint was a speech language delay and that turned into an articulation delay that was being addressed. But as far as all other milestones go, nothing reportedly an issue. Now, we do know there was a loss of oxygen at birth and that there was some time spent in the ICU. 36 hours is not a significant amount of time compared to what some of our other patients have spent in the icu. And this child was born pretty much full term, like when we shy of full term, healthy weight at birth. And again, no feeding issues, no Other motor issues that. That were reported, but enlarged tonsils and adenoids that were removed. And we. That kind of makes us go, huh. All right, so we know we have enlarged tonsils and adenoids. We know there's some inflammation. They fed well, though, so that's not a concern. But what, like, what are we going to expect to see in this email? And I know I'm talking to myself here, because this is a podcast and I'm delivering this to you all. There's no guest here today, so it's a little rhetorical, but I want you to start asking yourself, when you review a patient's case history, what are you gleaning from that? What, what questions should we be forming? What questions might we ask? So what I would want to know, right? So I might review that history before the patient comes in. And then what I might want to ask is, does this patient mouth breathe or does the patient nasal breathe? How's their sleep? If they had inflamed tonsil and adenoids, did the mouth close afterwards? Do they have therapy to help with closing the mouth? What are we going to see for oral rest, posture? How are they breathing? Where are they breathing? Is it down? Are they belly breathing? Are they using their diaphragm or are they, do they have shallow breathing? You know, it's kind of up in their clavicular area. Where are they, how are they doing now with foods? Are they still progressing? Any concerns? Are they picky? Are things going well? Where's that tongue resting? You know, and if, and if, if any of this is going awry, what is the cause of that? What is the root issue here? Because we had some, you know, I hate to call them red flags, but we had some red flags, right, with, with the case history. And we know there were ear tubes. We know there was a pressure equalization issue with extra fluid in the ears with inflammation. These are airway things, guys. These are. Everything's interconnected, right? So we know that things were not positioning correctly plus within. And that's when I talk about not position correctly. I mean, when you have to put in PE tubes, that means that you station tube is not draining properly. And the eustachian tube, for those who are not familiar, change. It changes its position as children go from infants to toddlers on up, right? Eventually it will be in a more downward angle on a. It's on an angle is what I should say, not downward angle, but it does point a bit downward. So the issue is that when children, because it sits more parallel to other structures, it doesn't drain as well, especially if there's inflammation. And so the fluid can back up. And that's where we get these kids who need these PE tubes. And ultimately the. This child passed hearing tests, but okay, they could hear, but was the quality of what they were hearing good enough? And I say good enough because, well, we don't really know. There's really no way of us measuring this at this point. If, you know, the tests back then didn't show anything alarming. But we have to wonder, this child's now in articulation therapy. Is it because they weren't hearing sounds properly and they learned to produce them the way they heard them? I don't know. These are just different questions that I ask myself. And obviously that one's a bit more of a speechy question. But the rest are all a myofunctional therapy question prior to that. So upon oral examination, I like to look at oral rest, posture, and I like to just kind of go through. I'm not going to take you through my entire assessment form during this podcast, but we're just going to talk about the findings. Okay. From the exam. So oral rest, posture, they. This child was a combined nasal mouth breather, meaning they were mixed. They did both. Sometimes they had the mouth closed, they breathe through their nose. Sometimes the mouth was open, they were mouth breathing, but it was high up there. It was kind of like higher up in their chest, towards their shoulders, up in that clavicular area, you could really see the movement of the breathing. Regardless if it was through the nose or the mouth. They were really doing a lot of shallow breathing and they were not using their diaphragm properly. Remember, this is only a five and a half year old. Excuse me. When the mouth was open, it was open about 9 to 10 millimeters. And yes, I measure this, but also I can kind of eyeball it at this point. And that was during the evaluation. Now, reportedly, the parent said that the mouth was closed at night when sleeping, which I was surprised about. It's possible, but we do definitely want to check in over time and make sure that's maintained. The tongue rests on the floor of the mouth, which is also why it surprised me that the mouth was closed at night. Because if the tongue is resting on the floor of the mouth while the child sitting in front of me and their mouth breathing, I really don't expect they're going to have a closed mouth when sleeping. That's not super common. It's possible, but it's not super common. As far as like facial measurements go like the philtrum. That was within normal limits. And I had mentioned before that there was a noxious oral habit, nail biting. Now the interesting thing that I have found about nail biting is if you treat a myofunctional disorder that typically resolves. It's not necessarily a habit that I have had to treat outright separate from the MYO program. It typically resolves when we can get oral rest. Posture corrected. During the eval, both of their nares were patent. So when we had them blow on a little, little mirror, the mirror test the nose, you know, the circles were even, they were large. There were no concerns there. And obviously this is just a very quick test that we do to see, like, okay, do we have major concerns? Is there congestion? Do we need to refer out? Sometimes this may, you know, one circle might be larger than the other and then we might look at their nose and go, oh, they have a deviated septum, you know, so it's a window into what else might be going on. But as far as the mentalis went and the cheeks and the masseters, those were all within normal limits. There was no, they had a gag. It wasn't an issue. We should have a gag. I hear all the time therapists say, oh, we got to get rid of the gag, we got to remove the gag. No, no, gag is actually a protective mechanism that we need to keep in place. And so we never want to get rid of it. We just want to move it back in the mouth so that it's toward the back of your mouth and it functions back there as it's supposed to. It's supposed to protect your airway. It's supposed to protect you from swallowing something that you shouldn't be swallowing or that you're not ready to swallow or that is noxious to your system for some reason. So, okay, let's see, where were we? So no issues with the temporomandibular joint. Also interesting, this child had a wide U shaped palette. It was high vaulted, but it was a yu. And there were no concerns with the soft palate, with the velum. Okay, so the biggest issue that I noted during this part of the eval, which is the initial part of the oral exam, was the mandible. Actually. Sorry, no. The mandible was also normal. Elevation, protrusion, lateralization was all within normal limits. Meaning they could do it. They had no mandibular or lower jaw involvement with the movements. Very interesting. They had primary dentition. Right. It's a five and a half year old child. They haven't lost any teeth yet. But what was interesting is that we've noted they have a high palate, a high vaulted palate, and their dentition, the lower central incisors, those two lower teeth that sit in the center on the lower jaw, they were turned inward, which tells me we need to rule out a lingual tie. Right. So when we look at the tongue, we did notice that sublingual tethered oral tissues, just sublingual meaning like under the tongue in an upper labial lip tissue, appeared to be present. And because this child had some good function and some good skills here, we weren't going to say, hey, you know what? Go right now to a release provider. We actually recommended that they be reassessed for tetheral tissues after three to four sessions because they had a restricted ability to suction the tongue to the palate, especially when their mouth was open. Right. So we look at things like can they suction their tongue to the top of their mouth with their mouth closed, shallow if they're having trouble? Okay, well, now if we slowly open it, can they maintain that suction? This child couldn't do that. So they could not suction their tongue to the top of their mouth with their mouth open, which is a measurement we also like to take to see how wide they can open while doing that versus how wide they can open without doing. Without suctioning. Just a mouth open wide. How open can the dog go? And so we wanted to give them the opportunity to practice and learn this skill because they're five and a half. If ankleglossia or tongue tie is. Was determined to be present for this patient, then yeah, it definitely can contribute to orofacial development over time beyond what we're seeing now. And it may be the reason for that high vaulted palate. Right. So it can also add to other issues like oral face feeding skills, articulation delays. Now, this child reportedly was a great feeder as a child, but we are going to discuss, we're going to keep talking here and see, like, do we think. And I kind of jump the gun here because I wanted to talk a bit about the tongue and what was observed. If we stopped here, we would assume this child had a tongue tie. But if we dive a bit deeper into looking, and I'm going to go through what I found when just looking at the tongue, and then we're going to talk about, you know, mastication, chewing and swallowing, as far as swallowing liquids versus food, their posture, and then we'll talk about recommendations. Just so you guys have a Gauge on where we're going here. So with this case, the tongue, like I mentioned to you, rests on the floor of the mouth. Okay. That's kind of like a symptom. Number one, we want to write down. Right. Or it was behind or up against the lower central incisors. So it was either kind of laying low and not touching the teeth, or it was up against those. The lower teeth, the lower central incisors on the. The jaw. They were able to elevate the tongue tip up to the alveolar ridge. Right. And so again, if you're not familiar with what that is, it's that bumpy region that's about 2 to 3 millimeters behind your upper central teeth. And they were able to do that, though, with a reduced open mouth posture. What does that mean? That means that they were not able to fully open their mouth without. With the tongue up on the spot. Right. If they opened it wider, the tongue could not reach the alveolar ridge. Another. Another interesting note to make here because we should have full range of motion and they don't. They were able to isolate the tip of the tongue when they elevated it and lateralized it side to side and protruded it. So that was great. Sometimes we have kids where they can't create that tip isolation where they point their tongue, but it remains really rounded. And they really have a hard time getting that isolation. They were unable to contract and relax the whole tongue, that whole skinny wide movement. While they were able to achieve tip isolation during elevation, lateralization, and protrusion, they were unable to contract and relax the tongue. We call that a skinny wide tongue. We knew that they couldn't do the suction of the tongue to the hard palate, but they were able to briefly click the tongue like a. Okay, so they were able to do a very brief click, but we couldn't suction. And so this was another thing that told me, hey, you know what? We might be able to work towards this. Let's see what happens in therapy over like three to four sessions and see if we can achieve this and then remeasure and look at what's going on. Because our therapy is dynamic, it's ongoing, it's ever changing. So it's not like the measurement we take today is our end all, be all. No, that's a baseline. And we're going to continue to investigate this. We are investigators, right? We're going to continue to investigate this as we go through therapy. So I want to really encourage everybody here to keep that in mind, because therapy Is dynamic and things constantly change, especially in a growing child. So we don't want to just take measurements on day one in the eval, put them in a drawer and not come back to them until they graduate. No, we need to be considering where do they start? Where are they today? Is this benefiting them? If not, what do we need to change? You know, we need to be asking ourselves these questions. These like, they're kind of like critical thinking questions are not just like, okay, we're going to go through the motion and copy this exercise and that exercise and this exercise and graduate them once they've done these 12 sessions. That's not mild. Nope, nope, nope. So that's a whole nother conversation. Let's go back to this case. So anyways, looking at the mouth open posture, this child was able to open their mouth about like 35 millimeters or, sorry, 40 millimeters. Mouth open wide. Okay. And we knew that they could not achieve the mouth open wide with suction. So we don't have a baseline for that. They can do a brief click. It's really shallow. And then what we want to keep in mind here, and I use these measurements from Sandra Holtzman, who I learned from this, is we're looking at basically that the maximum expectancy of the mouth open wide with the suction, right? So that mouth open wide with suction, that should be greater than half of the mouth open wide without the suction. So we have to. I wrote that I'm going to calculate that once the suction is able to be achieved. And again, it's nice to have numbers, especially if families are submitting to insurance or if you're in network with insurance. But numbers are not the be all, end all. There's a lot of variability and there can also be errors made, especially when we're taking these even with, you know, a tool in hand. So take it for what it's worth. We know this child appears to be restricted, but we're not convinced yet because we need some time to work with him first. Now let's talk about mastication. So, well, actually, let's do a liquid swallow first because that's really quick. So this individual swallowed puree from a pouch. And what we noticed was that the lingual pallidal suction also was not present while swallowing the puree. And so this was not truly a liquid. It was actually a thickened liquid. It was a puree. I usually have kids drink water. Sometimes they refuse and we can't force them. So this is what we were working with. This Now, I'm also not a big lover of pouches. They're fine for convenience. I don't love them as a staple in a kid's diet every day for reasons beyond orofacial development. They're also just full of sugar and oftentimes whatever the first ingredient is, whether it's apple sauce or whatever, you know, it's. They're not always as healthy as they're marketed to you. But I am totally a parent who's used them at a convenience, so I pass zero judgment. This just my little disclaimer on pouches. Okay, so moving on to chewing or mastication. This child had a combination of open and closed lips while mass, while masticating, primarily open. And there was definitely a tongue thrust present when swallowing. So when they swallowed, that tongue came forward, up against the teeth and or between the teeth when swallowing. And remember, the mouth was open. So I could see this very easily. Now why does that happen? You've probably heard me talk about this before, but that happens because we need to create negative pressure inside the oral cavity in order to close it off and swallow. And if the tongue is suctioned to the palate, to the top of the roof of the mouth, that negative pressure is easily achieved. When we are unable to do that or not doing it, now we have to figure out a different way to seal off the mouth to create that negative pressure. What does the tongue do? The tongue pushes up against the teeth to close off the spaces or even between the teeth and or between the lips, depending. We see all three presentations. And there you have a tongue thrust. That's that tongue thrust presentation when swallowing. Now this patient could. They could lateralize food to one side of molars and the other, and they had bilateral chewing present. And what I mean by that, this was a great question that came up actually in the membership was when we say bilateral chewing, we don't mean bite off food and split it between like the left molars and the right molars and chew on both sides at the same time. No, we mean bilateral chewing, meaning they don't just chew unilaterally only on one side of the mouth, which many myopatians do when they start with us. This child did not. This child actually would chew to on one side, move the food across on their tongue to the other molars, choo choo choo on the other side. And so that is what I mean. And then send it back and do it again. And that's that. That rotary chew that you maybe have heard us talk about in the Past and, or that's the bilateral chewing. They have the ability to chew and they do chew using both sets of molars, not at the same time, but cyclically. And then the bolus formation when they were done, that bolus is basically the chewed up food mixed with saliva ready to be swallowed. That bolus formation was one sided, it was mostly to one side of the tongue. And then if it, or if they didn't shape the bolus, because we look at multiple instances, not just one time thing in the eval, we noticed that the food was scattered across the tongue and they had a hard time even shaping the bolus. So it was either scattered or it was on one side of the tongue on repeat. You know, not on one side or the other side, just always on one side of the tongue. I didn't write down which side in the report, but I also had images which I obviously can't show you here that, that, you know, gave us this information in the report. Now, off of a spoon, we noticed the tongue came forward at times to receive the, greet the food on the spoon. And so what does that mean? That means that instead of the tongue retracting or staying behind the teeth to make room for the spring spoon that's entering with the food, it came out of the mouth or you know, to the lip or beyond the lip to basically quote unquote, greet the spoon. Right, so that the spoon went right onto the tongue. They did then put pull the tongue into their mouth with the spoon and they did use their lips to clear food off the spoon. Oftentimes when we see patients bring their tongue out, they don't always use both lips to clear the spoon, which is what we want. So, you know, so we're 50, 50 here. And then as far as the food swallow goes, we talked about, you know, chewing and prepping the bolus. We talked about, you know, what happens when there's a spoon involved, a utensil. But for the food swallow, the tongue thrust we know is present. Okay, so we've got that it was actually interdental, meaning between the teeth during the swallow. We know that the bolus was scattered. We talked about that and it was still scattered. Oh, I did write, I did write that it was primarily on the last side the food was chewed on. So I take back what I said earlier. This, this child, it did change based on where was the last animal or they chewed the food on. That's where the bolus remained. And they were unable to form a cohesive bolus most times. Also unable to completely Clear it, meaning I have them swallow and then they get one more swallow after that. We call it a cleanup swallow. And then it's still there. There's still remnants that they have not cleared. So they're unable to fully clear in what we would expect to be a normal number of swallows. Usually it would take them at least three swallows to clear. So we definitely see, you know, an oral prep phase and oral phase dysphagia going on here with posture. There were no postural concerns noted or observed during the evaluation, and that's through postural photos and discussion and history and, you know, looking at their. Their case and everything. It's not just asking the parent or taking a look at the child. No, we have like a posture grid, and you stand against the posture grid, or if you don't have a grid, you stand against the wall. And we want the base of the floor so we can see, you know, how the child's posture is. You can usually see if you take the photos head on, you can usually get a good feel for this. And actually, in the my membership we're going to be talking about this month, we're going to have a training on taking the best images in your mayo eval. So that's appropriate. So I'm not going to focus too much on the articulations. I really want to stay focused on the mild part. But I want you guys to know that an informal conversation and probing of the concern sounds was used. Not. We'd actually, I said earlier it was a speech eval. It was a speech eval, but we did not use a standardized test. And what I looked at was I wanted to actually observe the orofacial movement patterns during speech while they were talking. So I was more interested in that than getting a score on some random test, or maybe not so random, because there's some really good ones that we use out there. We did see that there was jaw, tongue and lip dissociation present during most sound productions and that there. But there was also a frontal lisp present on that. That's. That s. So there's an impairment there. All right, so moving on from that, I don't want to spend too much time on the speech component for this podcast, so we. Let's summarize this, right? Our diagnostic summary statement. What might that be? Well, the child has a tongue trust, right? We've repeated that a few times. That tongue forward swallow, we talked about they have a difficult time with two bolus collection swallow patterns. We know that that's something we need to work on we know the imprecise speech production or frontal lisp, whatever you want to call it. And so what would our recommendations be? Right, I'm going to pause for one second and let you think. Like, what would you recommend? I don't want to answer this for you immediately. I want you to think, what would I recommend in this case? Like, what would my course of action be? Okay. And because you can hit pause, since this is a podcast, we're going to, we're going to start talking again. And I wanted to give you a little five seconds of silence to think and pause and continue to pause a little bit longer if you need to. So, recommendations? We want to initiate an orofacial myofunctional treatment one time per week with a myofunctional therapist. Okay. I typically find that one time a week is sufficient. Other people prefer shorter sessions, twice a week. It really is up to you and the patient and what you feel best meets their needs. So I'm not going to get into a discussion of like, what should the frequency be and how long do you do it for and all that. Our sessions range anywhere from 30 minutes to 50 minutes once per week, usually depending on the case, what we're working on, and if there's anything else that we're addressing outside of the omd, the orofacial malfunctional Disorder, we want to eliminate that tongue thrust. Right? We want to, like I said in the diagnostic summary statement, we want to improve that. The chewing, the bolus collection, and the swallow. And we want to. If you're an slp, then you can also remediate that frontal lisp. Or if you're not, if you're an rdh, for example, or a dds, you can work on the MYO skills and then refer to a speech pathologist at the end if there is still a residual frontal list present. And I say that because sometimes correcting the oral rest posture and the swallow postures really help the child gain control over their tongue. And it might remediate that frontal lisp. Not always, but sometimes it does happen. I've seen it happen in my own cases. We don't always have to treat the speech issues separately for it all. And then other times we do, it just depends. But we want to make sure we have the right orofacial structures available and abilities available from an orofacial myofunctional standpoint before treating these speech sounds. Otherwise they're just going to be in speech for life, and nobody wants that. We also need to remember, rule out that So I wrote referrals, if you remember. I said, you know, I don't want to refer them right now for a frenectomy consult. But I did note, you know, a referral to a frenectomy provider might be a next line referral due to findings due to like, lack of lingual palatal suction, high vaulted palate. Even though they have this nice U shaped palate, generally it's still high voltage. So what's going on there? You know, so we want to look at that a bit deeper and, you know, if function does not approve after, you know, three to four sessions, if we're kind of still at a standstill and we have not made much progress, then that's when I would say, okay, let's go have that consult and get that set, get that additional opinion and see what our course of action is going to be specifically for this case. So I thought it would be fun to talk through an eval like this. This is one of your more straightforward, if you will, myo cases. There is a little bit of a speech component here, but I thought it would be fun to talk about this and just highlight some of the things that I feel are really important to gather information on in the history, what we're looking for generally during the eval. You know, even though so many things on this case seem to be within normal limits and there really were a lot of strengths for this patient. They still have an orofacial myofunctional disorder. Right. It only takes a couple things. And so I think that. And when I say a couple things, I mean like tongue thrust, scatter, bolus, unable to clear that bolus. Right. Tongue coming forward to greet the spoon. We know there are some things going on here. We also know this child has had a history of inflammation. They've had their tonsils and adenoids removed. They had the pe, the pressure equalization tubes in their ears as a two year old. You know, we know there's a speech, well, speech and language delay. Right. And so we know there's some other things going on. And so this is. It's definitely better to treat this now versus waiting for later. But because a child can briefly click their tongue, you know, I wanted to be able to work with them and figure out like, hey, can we turn that brief click into a longer suction hold? And then can they, can they, can they hold it for 10 seconds, 20 seconds, 30 seconds, 45 seconds, a minute, two minutes? I don't know. Um, I don't usually always go up to two minutes with my littlest ones, but I definitely want to know that they can hold it for 60 seconds and maintain it because if they can do that, then we're going to have a much easier time getting that present when we want to swallow our prepped bolus and also getting that tongue lightly suctioned or resting up on the palate at rest as well. So fun case. If you guys like these, let me know. We can always chat through more cases on here, but I just thought like it would be fun to change it up and talk about this, especially because I'm in MYO mode with creating the MYO course and we will be talking more about mayo over the next couple weeks. So again, let me know if you liked this and we can if you want more case studies, we can definitely share some case studies. And if you're somebody who wants to come on and share your case study, you are more than welcome to do that as well. Just reach out to us. Hope everybody has a great day and we'll chat soon. Thanks for listening to this podcast. If you want to hear more of these Myo Tots, Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts or pledge a small amount on patreon.com the untethered podcast if you found value others you know in the so be sure to share this episode on your social media platforms and join us over on Facebook on my Facebook page at Hallie Balkan Biz, on Instagram @hallebulcan. 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.