Episode 147: TOTs and The Impact on Feeding

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. Hi and welcome to episode 147 of the Untethered Podcast. Today we are debunking some of those other myths like I mentioned at the end of the last podcast, and really focusing on tots and the impact on feeding as well as what's going on in the research space. I'm not going to dive into the research that's out there right now, but I want to talk about why it's challenging to do level one studies, random control trial studies, RCTs on infants who have feeding issues. So let's dive in real quick before we jump in. I'm Hallie Vulcan, your host of the show and it's just me and you. Today we do if you're an SLP or an OT and you're listening to this on the date or the week that it airs, we have a five day challenge coming up. Free training and challenge to screening your first pediatric feeding patient that will take place between January 31st and February 4th, 2022. Yay. Go to FeedThePedes.com training and you can get all the details you need right there. All right, let's jump into this episode. So as promised in the prior episode, we're going to debunk the myth that feeding is not impacted by tots or tethered oral tissues like tongue tie, lips ties, cheek ties, and that only infants who are breast or bottle feeding benefit from a TOTS release. Because we have people who feel who are kind of in both of those camps or some who say, oh well, yeah, I mean obviously it impacts infants who are just feeding on breast or bottle. But yeah, once foods are, you know, when solids are introduced and onward through adulthood, yeah, it has no impact. False. Majorly false. So first, I also want to explain for those of you who are not in the medical space, I want to talk a little bit about what's going on because there's this big like, you'll see words thrown around like, oh, this is EBP or evidence based practice, or we follow science or you know, it's a level one study or there's no research to support this. You hear a lot of this jabber going on and I want you to understand firsthand why things are the way they are so that you can have an appreciation for why those, the professionals out there who actually do work with these children and who treat them firsthand have the viewpoint that they have. So I also want to point out there's a lot of providers like speech language pathologists, feeding therapists and many others out there that also have a large social media following who unfortunately provide very dangerous and or harmful information and misguided advice. And so I want you to be careful who you follow. It's really unfortunate and quite scary. So it's great to get some medical advice from, you know, the gram or the book or the talk. I won't say their full names, but at the same time do your due diligence and ask others, especially if something feels off to you. I've had a lot of parents come to me like because of other accounts and forward me things be like, what this, like totally contradicts what you say or she seems to be mocking this or this person's supposed to be rooted in the research according to what they do, but this makes no sense like, and I think that speaks volumes for parents to be sending me messages like that and realizing that yes, just because somebody claims to be like in the research space or they claim to call themselves a feeding specialist, it really doesn't even mean that they're fully, that they're actually trained in TOTS or MYO or airway to the extent that some of some other people are. And so I always invite people to come to me and inquire if you need a specialist and I will try and help you find somebody in your area who's qualified. Because while I can't vouch for many other people out there besides myself, my team and some few of my colleagues who I've seen, you know, their work firsthand, I can at least look at their credentials, look at the courses they've taken and look at what information they put out there to understand that this is going to be somebody who is on the same page as you and, or give you the questions to ask and have you reach out to them to figure out if it would be a good fit for you and or your child very passionate about that, because unfortunately, it's very challenging to find a good provider who's actually going to do therapy that's beneficial for your child. And so just going to leave that at that. Okay. And that, that's not just in my arena, that's across disciplines when it comes to tots and mayo and feeding. All right, so let's see what else I can tell you. Well, you know, let's take this, and we're going to go right into our next topic. So I want to use that. I want to kind of continue on with that example. Many will say there's not enough published research to support releasing tongue ties in children or adults. Okay. The truth is they are highly misinformed. We may be able to do retrospective studies. That would be like a level two study, maybe. But we cannot do a level one randomized control trial or RCT study in infants, as I mentioned before. We may be able to do a retrospective cohort study, as I just mentioned, but again, that would be like a level two, and sometimes maybe even not, depending on how it's done. And what's challenging is that people use this as a reason to not treat certain issues in infants. And then if it's not a level one or two study, it's also highly dismissed by many of my colleagues. So what I want you to, what I want professionals who are listening to do is I want you to challenge yourself and put on your critical thinking hat and realize that just because research isn't done, because sometimes it can't be done, we need to turn to the specialists who treat in this space, who work with these patients, who are getting results on a daily basis and helping improve function, who are consistently refining their collaborative care team and their approach and their treatment interventions to continue to best serve their patients in treating the root cause and allowing that little patient or family unit to function optimally. We need to be looking at those people, and we need to be looking at what these individuals are doing, what they are teaching. Are they keeping people on their caseload for life or are they getting patients off the caseload eventually? Are they, you know, is everybody getting a release or are some people getting a release? There's certain things that you can look into, because I can tell you, in my practice, not everybody gets referred for a tongue tie release right now. Do we have a lot of kids who do? Sure. Because people come to us as, like, sometimes they find us, they travel to us as a last resort because they've been to so many other providers closer to Home and, or, you know, people that they were referred to that unfortunately totally missed the tongue tie or didn't realize that they needed to look under the tongue because they were never taught that. And, and look, you only know what you know, right? But once you've been exposed to it, if a provider has been exposed to it, they've been trained, they've taken the courses and they choose to ignore it, that's malpractice. And there are people like that on the gram and on some of these other social media sites that are spewing, excuse me, they're spewing a lot of misinformation. So I want you to keep in mind that our goal is to help everybody function optimally, whether an infant or adult. And so this is why I'm very passionate about talking about and teaching on this topic. All right, so why can't, because, you know, you guys keep hearing me say like that we can't do certain types of studies in infants, right? Well, I was like googling around on this because I am not a researcher, expert or anything, you know, a research expert. I can read research, I can make sense of it. I was taught, I took a, some courses in both undergrad and graduate school and I was taught how to like break down these research studies. And I'm not going to lie, it's not my favorite thing. I don't, I don't stay up late at night doing this kind of stuff. I do other things, I create other kinds of courses. I research, I do, you know, follow research. But at the same time this was just, it wasn't my passion. And I think that that's because in the areas that excite me most, sometimes actually the areas that are hardest to research because of certain rules out there. And so I found a really great article by Cedars Sinai that I will attach to the show notes. But I thought they could have gave a really great explanation on why children, especially infants, are challenging to study as a group and conduct clinical trials in. Because what they highlighted especially, and I pulled out some of these highlights, are really critical in understanding my point here. So I'm going to quote them, I'm going to read this straight from the article they wrote that children are a complicated group to study. Researchers can't lump all children into one bucket. Testing a treatment on a 17 year old is not the same as testing a treatment on an infant. That's just one reason for the seven year lag time on average, meaning it could be less, could be more between an adult approval and a pediatric Approval for the seven same agent. That means adults have access to effective treatments years before they're available to children. Okay. Now, per Dr. David Ziering, who was quoted. He's an associate director of pediatric inflammatory bowel disease program at Cedars Sinai. He said principal investigators for pediatric trials provide focused care and attention to kids in these trials simply because children's bodies and minds are still developing. Okay, So I just, I pulled out some interesting things that I thought were worth noting. Right. What does all this mean, though? Like, what does this mean when it comes to clinical trials or randomized controlled trials? And, you know, clinical trials can be things for that. It could be a certain treatment or surgical intervention. It could be a medication, it could be a vaccine. It could be all kinds of different things. Right. So what we need to understand even further that this article goes on to explain. You can go read it for yourself. Is while clinical trials for children are run similar to those for adults, there are some key differences pointed out. And don't worry, I'm going to get into how tots impact feeding shortly. We're almost done here, but I wanted to point this out. The key differences, they talk about informed consent. Children's trials come last, and placebo use. Let's talk real quick about informed consent. Basically, with informed consent, children and their parents, depending on the child's age, they have to sign separate informed consent forms agreeing to participate, saying that they've received. Giving your informed consent. We've been informed. We consent to participate. They want to make sure the child is willing to. They're a willing participant in the study. Now, children's trials come last. What does that mean? I'm quoting this directly from the article because it was so beautifully written. I'm not going to rephrase it. They said studies that are randomized and controlled set out to identify effective treatments for a particular condition. These trials occur only after preliminary research shows the agent is safe and effective in the lab, then in animals, and finally in adults. Kids are always the last to get tested with a new treatment. According to Dr. Drauliuk, by the time researchers begin trials for children, we know the intervention is safe and effective in adults. Okay, well, that's promising. Obviously, little, you know, infants and toddlers are not adults, but look at the process that things have to go. Go through before they even tested on children. But what I mean, and the reason I'm getting at this, you guys, is because we can't do a study that says, hey, you know what? Your kid has a feeding issue. We're going to give some of you a frenectomy, and we're not going to give some of you a frenectomy and you won't know what you're getting or what you're not getting. Well, first of all, impossible. If you have a surgical procedure on your child, you're going to know, okay? So there's no way to do a double blind study on a procedure like that. Number one, it could be. The researchers could be blind to it, but the parents could not be blind to whether or not their child underwent a surgical procedure. They're going to be. They're going to know if their child got their tongue clipped or not. They can lift the tongue up and look right, like it's. It's not like, you know, swallowing a placebo pill and one is the medication and one is not. It's a little bit different. Different. But in general, as far as placebo use goes, clinical trials for children generally don't include placebos, period. Okay? Because if there is any evidence, this is according to Dr. Ziring. Again, if there's evidence that a treatment works well in adults, it's not ethical to expose a child to a placebo and withhold a treatment that could improve their condition. Okay? It is unethical to say, you know what? I'm going to give some of you a procedure that I think you need, and I'm not going to give some of you a procedure even though I think you need it, because we have to prove it through a study. It's unethical. It won't be done. It won't be done. So instead we have to get really crafty with how we study this, right? We've studied swallowing on. There's some research coming out on ultrasounds on swallowing, on infant swallowing, watching, you know, what the oral structures are doing in the tongue. And then you can, you know, you can visualize what's happening during a swallow. We could do a retrospective study. Again, that one would not be a level one study, but we can do a retrospective study looking at children who got it and children who didn't. But again, that's challenging to do because there's so many variables at play that to create a really well done and highly respected study, I mean, this is. It's not easy, okay? And I'm not saying don't do it because it's hard. I'm just saying it's really challenging to do it and to get information that's going to be beneficial to us clinically that we're not already getting. We're already getting this information just simply by treating these children and working with providers who are highly skilled in this area and getting health back on track. And when, you know, if our, let's say our marker is whether the child feeds or can't feed. Well, if the child comes in and they can't feed. And we do some feeding interventions and sensory, oral, motor intervention, it's worked on other children, but it's not working for this child. And we see the child has a tongue tie and it's been confirmed by another expert in this space and their issue persists. But then all of a sudden, following the release and as they heal, we notice that feeding starts to improve because now they have full range of motion, their tongue. When you start to talk it out loud and you start to think about it, it makes sense. It makes sense that that would work. It makes sense that you don't need a study to prove this clinically because we already, we're seeing this clinically and we're seeing this in hundreds and hundreds and hundreds of patients. This is not just like, oh, that worked for this small group over here. No, and it's probably more than that. I'm just talking about the cases that I'm privy to that I'm aware of through colleagues, through my own practice, through colleagues practices. I'm sure there's thousands of patients out there that have had positive experiences with this. Otherwise we'd be seeing some big class action lawsuits against these doctors who are doing these procedures if they were causing harm. Right. You know, once in a while you hear about a case where it didn't work or you hear about a case where something went wrong because that's what happens. And unfortunately that's medicine. That is medicine. There are always risks. Right. I'm never going to say there's not a risk and I'm never going to guarantee that this is going to work 100%. But usually the risks, the benefits outweigh the risks. And this is a procedure that does not, if done by the right person, it's not generally a dangerous procedure. Okay. So that's why I'm very, very keen in on feeding therapy and the right approach and the provider using the right tool, who has the right level of expertise and really going to who is recommended and not just who is in network, in your insurance, unfortunately. I know that's a frustrating thing because even, you know, as someone who pays out of pocket for my own insurance, yeah, I would love to go to all in network providers, but sometimes I'd rather go to the expert in the space and pay out of pocket when I'm able to, because I know the outcome is going to be better and I know that's going to directly impact me holistically, like throughout my body. Right. So, you know, we as a society, and I'm like, way off topic, we're going to get back, back in, in a second. But we as a society needs to do better by our patients. And it would be really great if insurance companies and plans were actually paying us enough money to keep our businesses running and paying our teams so that we could accept insurance and things could be covered. But unfortunately, we are in a day and age where the, you know, I'm getting really political here, so we're not going to go too much further. But really, the doctors, a lot of the doctors are not making what they used to. And the clinics, like speech pathology, OT clinics make peanuts if they're in network with most insurance companies. And so it's, it's very challenging. So maybe if someone's interested in that kind of advocacy, you know, go for it because I don't have the time, but I'd love for someone else to on that project, have fun, go advocate, get insurance to cover the services that our children need, especially when it comes to airway. Right. Airway and feeding. All right. So, you know, I just, I'm going to say again, that was from Cedars Sinai and you can look at clinical trials in children. It's an article on their website, but we'll, we'll link it to the, to the show notes for this episode as well. But let's talk about, you know, now that we've established that Level 1 RCTs are really not going to be done in infants and toddlers who may need a TOTS release, like, they're not going to withhold that. Let's recognize that breastfeeding imaging studies that I mentioned and any future retrospective cohort studies that may be done, if that's the best that we can do from a research standpoint, like, let's respect those and understand that that is research worth reading and seeing what happens when they, when they go to research it. But really, if you're a skilled clinician who can think critically, you can also, like I said before, see patterns in your patients. You can come to recognize when something is harmful or helpful or just neutral or, you know, working, not working. Right. And you have to get comfortable living and working in the gray zone when you do, when you work in feeding or you work with TOTS patients or Airway patients sometimes, because sometimes you have to tweak as you go. Right. It's very dynamic type of therapy. So let's talk about the impact of tots on feeding. I have a lot of information for you here, but this is going to be like I actually took a lot of this out of my feed the peds course to give you a little teaser for any of you SLPs or OTs who are listening who haven't taken the course yet. What happens if your tongue is restricted? Well, we know it's generally tied to the floor of your mouth, has trouble elevating, can't achieve tongue to spot lingual palatal suction or other lingual movements that are necessary during the oral phase of the swallow. Let's go right into the swallow here. Oral phase first. For infants, it slows the flow of milk that's pulled from the breast or bottle nipple. And it's like a safety mechanism too. Right. They need to be able to control the flow. Munch pattern of chewing versus rotary pattern of chewing is common. We see a lot more munching because the tongue is having a hard time lateralizing food to the molars to even begin chewing and then moving it back to the other side and forming a bolus. Right. We see a lot of stuff, single sided chewing going on. They may overstuff their mouth with large bites of food. Food might get trapped in the lateral sulci or we will see pocketing restricted ability of the tongue. The tongue may not be able to clear that space as well. They might see them using their fingers. We see tongue dumping just kind of like where the tongue comes up and stands on its side like a dump truck or humping back where it's just not functioning or moving properly in trying to do its job. And we may see a thrust forward, right. To come in because we say greet the cup of water or the utensil, the spoon or the fork. The tongue might push against or between the teeth when swallowing to create that negative pressure is needed to generate that swallow. So these are all really important things that we need to pay attention to because there are more things that can happen. I'm just giving you a brief list of some of what we see going on. Right. And then what happens if your lip is restricted? Well, for infants, if it's uncomfortable, they're going to have a shallow latch. They're not going to do something that doesn't feel good. So we need to keep in mind that if they have a shallow latch and they're, they're not Engaging in a deep latch. Right. Because it hurts. Well, there's a reason for that. That child latch also restricts the flow of milk. Right. So we need to keep that in mind. And then for breastfeeding moms, you know, nipple shields are great, but they're meant to be a temporary aid. They're not meant to be something that they use throughout their entire breastfeeding journey. So, you know, we do look at that. Aerophagia, swallowing too much air. We commonly see this in infants, but we might see this in older kids too. And aerophagia induced reflux is often misdiagnosed or treated as gastric, you know, as ger or gerd. Right. Gastrointestinal, sorry, gastroesophageal reflux or reflux disease. Leakage of milk due to the inability to close off the mouth. Right. That's a problem we see quite frequently, especially with infants. But I see it in my toddlers too. And I see leakage of food, not just liquids, lips that just can't close any further to promote, you know, and they actually not to promote, but they do promote a tongue thrust. Right. Because again, we need that negative pressure in the oral cavity or in your, inside your mout to swallow, to initiate that swallow. And so the tongue will come forward if the lips can't do their job. It's harder to manage saliva. So we see a lot of kiddos who drool a lot. We may see them soaking like masks if they're still mask wearing or their shirt or their bibs. It's harder to drink from a straw or an open cup. That was true for my own child. It's harder to achieve a closed mouth posture arrest and when swallowing. And we see increases in illness, upper respiratory issues because they're just taking in bacteria through the mouth, not filtering it through their nose. And that can be really challenging. But they, these kids often get sick more frequently than their, their same age peers. All right, let's talk about cheek buckle ties or what happens if your cheek is restricted. These are the often forgotten buckle ties, right? Because yep, there's a lack of research here. But hey, as I mentioned in the prior episode, there's four. We've got two upper and two lower. There could be more, but they're uncommon. So we usually focus on the 2 and 2. They do appear to impact the following list that I'm going to read off for you for some patients. Okay, so like for infants nursing, nipple stabilization for really across the board, any age, cheek activation with solid feeding and chewing, there's facial or oral tension again, across the board. There may be gum recession in older children and adults as a result of those cheap restrictions. And that's one of the primary reasons that dentists often will, will release them, even if they're not somebody who's in, like, the taught space. It may be because of gum recession, but just something to be aware of. Now I want to talk for a few more moments before we wrap up today about ties and toddlerhood. And then we're going to go into, like, ties and older children and adults. Okay? Because toddlers can absolutely be treated with success. Do not write these kids off. If you've been following me for a while, you know this already, but I just want to highlight it again. When solids are introduced, like, we may see eating difficulties appear then in infancy, but sometimes they don't resurface until toddlerhood. And these can be, this can be true even if your child was released at an earlier age, whether they were fully released or not. Sometimes there's just challenges develop as certain skills get harder and certain skills should develop that maybe are delayed or that don't develop as they should. And then they need some intervention, they need some help. But these kids are often labeled like slow eaters, picky eaters, messy eaters, lazy eaters, you know, so on and so forth. But how? I always like the question, how do we know if the feeding issue is due to ties or like the terrible twos or three majors, right? This child is being difficult because of their age. Well, you do a thorough assessment and you pay particular attention to their eating schedule and their eating habits, what they eat, how much of it they eat, how much liquid they take in versus solids, you know, on a, on a daily basis, the length of time, the type of foods, and so on and so forth. Like I'm just summarizing here. We also need to rule out tots and airway and sleep issues and behavioral issues, all these different kinds of things. And we should be inquiring about their full medical history. And the youngest ones, it's really helpful to understand. I mean, hey, if they're older and you can get this information too, that's always awesome. But parents don't always remember. And the youngest ones, really helpful to definitely ask about the medical history dating back to, like, conception. Like, how was that pregnancy for you, Mom? What, you know, how was birth? You know, what was a birth history? Like, did anything remarkable happen that, you know, any struggle for you or baby, how was delivery? You know, how are, you know, post delivery? What, what went on how to, how was the feeding going? Like when you brought baby to breast for the first time or you gave baby a bottle for the first time or you know, when you introduce solids for the first time. We need to be asking these questions and this is something that I'm not going to spend a lot of time on here, but we dove into teaching you how to do all of this inside feed the peds course. So little plug for that again. But let's talk about ties and adults and then we'll wrap this up today. So I have some very specific questions that I like to ask about my older children, my teens, my adults. Because I found that so many, there's so many adults walking around with picky that are picky eaters, but tongue ties. And so I always like to ask, and I definitely ask this for like our toddlers, but we ask has this been going on for a couple of months or is this something that's been going on much longer? Right. Because especially with like picky eating, there is picky eating that is normal to a certain degree in toddlers. And if it lasts for a couple of months and then they start to grow out of that picky eating stage, it's just a stage or a phase. Right. But if it's persisting and then let's say they're eliminating foods, that's a problem. Right? If they have 20 or less foods that they eat, that's a problem. Especially if they start to cut it down to 15 and then 10 and then they're down to 5 and then the parents are really stressed and freaking out. So I like to find out a bit about that information and I'll ask adults like, do you remember, have you always been picky? Because sometimes they'll say, oh, I've had dental work or my tmj, or there's something else that has maybe led to them being very selective about what they eat. So that's why medical history and understanding their, their concern and what they're coming in and reporting on and asking a ton of open ended questions is really beneficial. But for adults I love to ask about like textures and temperatures and size, shape, colors of food they eat. Do they have brand preferences? Obviously we're going to gather this information in our younger children too, but it's obviously oftentimes going to be reported by the parent or we're going to observe certain things in our evaluation or in therapy. Right. But adults can tell you they can very easily answer these questions for themselves. I like to ask if they prefer foods that are like, easier to chew and swallow or if they eat like a ton of grill, you know, do you eat grilled steak? Do you eat grilled chicken? Do you eat soup with stuff in it? Do you. Is it easy to eat that? Do you just eat it because you like it? But it's really hard to eat. Like, I try to dive into this because sometimes people will eat things that are highly motivating because they love the food, but it's really challenging for them to eat. I've had kids tell me tacos are really hard because of all the different, like, pieces and things that go into it and the different consistency. You know, there is like, maybe there's some wet salsa and it's kind of drippy and then there's the rice and then there's the lettuce that's crunchy and maybe cold, and then you've got the chewy, you know, piece of steak. And if it's a steak taco, you know, I don't know. I'm just giving an example. But the bottom line is that can be a really challenging food for some people to eat, as can soup with pieces of food in it that may need to be chewed, that aren't so, you know, so mushable, if you will, like, if you have chicken in the soup. So I just want you to keep this in mind as you're talking to. If you do work with older kids and adults, especially if you do myo, this could be really great to ask about. I ask, like, do you ever hold food in your mouth? Like, do they pocket foods? Do you ever spit foods out because they feel weird, or you can't chew it well enough, or, you know, like, that grizzle on the steak is just give you the heebie jeebies and you're like, ah, I can't, like, I can't stomach this. And so you have to spit into a napkin. Do you know, if you refuse to foods when you were younger? Or are there certain foods that you eat now that like, you know, you used to eat, but you just can't eat anymore? And like, did anything happen that you're aware of that has triggered that? And keep in mind, these are questions not just for adults, but for, like, you know, younger children, even elementary age as well, up through adulthood, you could, you could ask about some of these things. Have they always been, you know, this is going to be more relevant to younger children and teenagers, but have they always been on their own growth curve or are they just small for their age? If they have reported that they're small for their age because a lot of our kids are not all. Some of them are in the 90th percentile and some of them are right there in the middle. But some of them are also really tiny and on their own growth curve. And then I like to ask about, like, infant feeding. Do they know, did they breastfeed? Were they able to. Was that hard for their mother, you know, to. To do with them if they're an older, you know, if they're in their 20s, on upward? Like, I will ask these questions. Do they know if they had any feeding issues, you know, early on, even when they were a young child? Like, I can remember back myself that dairy was hard for me to digest. Like, I know that I had an allergy early on in life and then I developed a lactose intolerance. So I often avoided dairy. Otherwise I didn't feel well when I ate it. You know, I know certain things about food. So what are their food stories? What are their food experiences? Experiences? Get that information from them, right? Because maybe they've had issues, but they've adapted or learned to compensate with certain things. Maybe they had issues that no one realized were issues related to potential tongue tie. And so you may be like unraveling something and kind of laying something out on a platter for them for the first time where they're going to go, why didn't anybody else tell me this? And it's going to help you get into whether or not there may be some, like, sensory, motor, feeding things going on. Because, yes, those exist even in adults. Do they have a heightened gag reflex? Any history of coughing or choking when eating? You know, these are things that they also may say no to, but maybe they do. And maybe you'll observe it during your evaluation or in therapy. Like, I have a family member who doesn't observe that they cough frequently on thin liquids, but they do. And they're severely tongue tied and just not willing to hear anything. So, hey, you know, by all means, like, I've done my best in just bringing it to their awareness because there's some. Somebody close to me. But what they choose to do with that information is on them, even though I am a specialist in this space. So that's that. So I hope that this was helpful in giving you a little bit of information in terms of debunking the fact, you know, or the myth that feeding is not impacted by tots, because it is. And it is. You know, it's not just for infants who are breast or bottle feeding. No tots exist and sometimes, you know, need to be released across the lifespan, not just for our infants who are breasts or bottle feeding. And I hope they also help to shed some light on why certain types of studies would not be appropriate for our youngest patients, our infants and toddlers. Because it's just. It's not, it's not. It's not ethical. Right. It's unethical and we can't. The clinical trials, as I mentioned for children generally don't include placebos. Well, that makes it challenging to do some of these, like double blind, you know, RCT level one studies. It's just not ethical to expose a child to placebo and withhold a treatment. They can improve their condition per doctor's eyring. So maybe we'll wrap up on that today again, if you're an SLP or OT, join me January 31st to February 4th, 2022 for free training how to screen your first pediatric feeding patient over five days together. You'll get five free hours on a certificate of completion. If you end up joining the course, we will include those hours in your CEUs. You'll get five additional CEUs on a certificate if you become a member of Feed the Peds when Doors the course open February 7, 2022, so you can get on the waitlist@feedthepedes.com for that. But join us for the challenge. Feedthepedes.com backslash training I cannot wait to see you guys in there and I will talk to you all on the podcast next week. 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 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 @HALLIEBLCAN BIZ, on Instagram at Alibulcan. 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.