Episode 163: 3 Most Common Questions Regarding Feeding and Myo

Hi and welcome to episode 163 of the Untethered Podcast. Today it's me, your host, Hallie Polkin and we are going to be chatting about some of the most frequently asked questions regarding when to have a myo eval and how we know if one is needed, what to do if airway issues are present in your child, and some tips and suggestions on what to do with picky eaters. So let's go. 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 content, 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 is let's get started. Hello friends, it is your host Hallie Balkan here and we are going to chat today about some frequently asked questions that I get in the feeding and myo world. There's a lot of confusion out there and so I thought let's take a couple of the biggest questions I get on social media, whether it's from parents, providers, providers who are in the space, who are not yet in the space, and I try to narrow it down into a couple general topics. One is how do I know if I need a myofunctional or an orofacial myofunctional evaluation? That's one of the questions. Another one is what do I do if I know that my child has picky eating issues, sensory, motor, feeding issues, whatever you want to call them. How do I know what do I do if I know that? This is always tricky because it depends whether you're working with somebody or not as to how I'm going to respond, but we'll talk about that and then what do I do if I know my child has airway issues but I can't get anybody to help me? Okay, so I want to talk about those three things because I think they are topics we can cover really quickly, but topics where if you just have some of the right information, you can proceed forward and you'll feel really good about knowing the next steps. Right? So let's Go back to the first one. How do I know if I need a myofunctional evaluation or an orofacial myofunctional evaluation? So what I want to say first, I want to preface this with if a child and we're going to talk about, we can talk about children and adults for this one because my goes across the span of the lifetime. If a child is under the age of four cognitively, that means that they are functioning at lower than what you would expect of a four year old child. Okay? Cognitively I'm not talking about their actual age. Cognitive age and chronological age are two different things. Chronological age is like, hi, I'm Hallie, I'm 36, right. But it's not the number that you are age wise, it's the level at which your brain functions. That's what I mean when I say cognitive age. A child is at least at a four year cognitive age, then they can typically have a traditional orofacial myofunctional evaluation. Now if they have a really hard time sitting still, which some four year olds do, and that's okay, then maybe they're not ready for a traditional eval, but maybe you can still do a myo eval and just modify it, see what information you can get and gather other information going forward in future sessions. Working with the child, if therapy is recommended, that is something that we do in the therapy world. We call that dynamic assessment. We don't always get all of our information in the first evaluation and that's okay. We get as much as we can. But we want, especially with young children and older children too, we want them to like us, we want them to want to come back, we want to give them a reason to trust us. So if we try to push, push, push to look under the tongue and get in the mouth and do all these things just because it's on a checklist, we're going to lose their trust and we're going to lose the window in which we're going to be able to get, gather really good data at a, you know, at a quicker rate. But if we can build rapport, even if that means we get a little bit less information in that first evaluation session and we decide, you know what, we have enough information to know that we need to proceed, then in the second session or the third session or so on and so forth, we can continue to gather more information. And we do that anyways. Any therapist who is working with a child should be looking at what skills do they have today? What are they struggling with today, what are they excelling at today? Is that carrying over from this session to the next session to the next session, are we seeing, you know, they have certain skills, but they're not really maintaining them week to week. What's going on? We need to be assessing this every week. And that's why sessions take a certain amount of time. But I also share this because there are certain programs out there where every child gets 12 weeks and I give you the same, you know, everybody gets the same exercises, week one, everyone gets same week, two exercises, week three exercises, so on and so forth. That is not myo, that is a cookie cutter program. And we get a lot of kids from those kind of programs where they haven't achieved, forget about maintenance, they haven't achieved the skills to begin with in order to even move towards, you know, honing them and making it a part of their automatic behaviors or basically moving it into what we call maintenance. Right. They're not maintaining those skills because they never really fully developed them and had them in place to begin with. So kind of went off on a tangent here, but myo eval, right. So if you're under the age of four, then you're going to want to work with a speech pathologist or occupational therapist who is trained in feeding myo and tethered oral tissues, typically. And so that's like something I teach, for example, in my feed the peds course at FeedThePedes.com, which by the way is, if you're listening to this in the week that it goes live, the doors to that course will open on Monday next week, on May 23, 2022, if you're an SLP or OT. But for a myo eval, we are going to recommend a myoeval if an orofacial myofunctional disorder is in play or at play, and if we're concerned about that. And what does this look like? Well, maybe they're a thumb sucker or they put other things in their mouth and this is a habit that they're doing and they're non food items, maybe they have a habit of their mouth sitting open. Tongue could be back or forward in this case, but if those lips are apart, whether, whether they're playing or they're sleeping, whatever they're riding in the car seat, if they're not talking or beating, that mouth should always be closed with the tongue up on the palate, breathing through our nose. And if we're not seeing this, if we see a tongue coming down and forward through the teeth, or it's resting against the teeth and the lips are open. Tongue is thrusting forward or out of the mouth. You know, these are things that tell us we need a myo eval. So I like to say, and this one, this is a good one to write down. Tongue up, lips closed, teeth apart, breathe through your nose. When you remember this, if we have trouble with this, whether it's a child or an adult, and this starts at birth, babies should have closed lips breathing through their nose at birth. Now, obviously, babies need to be suctioned when they're first born and adjust to the world and everything. But that first day of life, they should really be laying there with lips together, breathing through their nose. That tongue should be up on the palate. This happens in utero. This is not like, oh, after we're born, we eventually gain these skills. No, these are there when the baby is born. That's how we know if we need a myo eval. Those are some general tips just to know how do we know if we need my eval? Who do we see? Based on my child's age and adults, obviously a myofunctional therapist, which can be slp, ot, an rdh, was a registered dental hygienist. Some dentists might be doing it, and there may be some other providers, too. But you have to look into who is this person that's doing myo, because there's a lot of people teaching it to whoever will pay them, and they are not all qualified or licensed to do this work. And SLPs and OTs and RDH, as we all carry licensure and dentists, that includes myofunctional therapy in our scope of practice. So just going to plug that real quick. All right, so moving on to airway issues, let's do airway issues, and then we'll talk about the picky eating and feeding side of things. So airway issues. If you think your child has an airway issue or you know your child has an airway issue, this, this is one of those trickiest ones that I get. A lot of parents, you know, and even providers trying to help parents in my inbox, asking me on social media, like, okay, I, I see what you're saying. I know we need help, but I can't find anybody to help me. And this is really tricky because a lot of people will say, oh, go see an entire. Well, a lot of ents are going to take a quick look up the nose in the back of the throat. If the child's not chronically ill, they May send you on your way. Others may give you an antibiotic or a nasal spray, say, come back in 30 days. And then child seems to be okay in 30 days, send you on your way. Issues are recurrent. They continue to happen, right? Some will even say, oh, it's fine. Your child's mouth breathing, oh, snoring is not a big deal. Pediatricians say this, ENT say this. There's all kinds. There's SLPs and OTs who say this too. It's not specific to 1, 1 arena, but those of us who are specialized in this and who look at anatomy and physiology and understand how the nervous system works and understand holistic health, we know we should never mouth breathe, we should never snore. This is actually an alarm going off that tells us, hey, we need to help this child. So what do we do? Because it's been so hard to find ents. And don't get me wrong, there are some great ents, but they're few and far between in the United States at least. And so what we end up doing is we end up referring a lot of our children to pediatric dentists. And sometimes there is the airway orthos, but the pediatric dentists seem to be the ones who are more getting to be more in the space. And it's not every dentist. You can't just go to any dentist and have a conversation. You have to look at an airway dentist or a dentist who is using growth appliances and not just expanding laterally. And so when I say laterally, and I'm going to try and use very simple language because I want this to be geared towards anybody who's listening today. And not really, I don't want to give you more terms to look up, but when we talk about expansion appliances, number one, there's more and more being done for early intervention, like starting at age two. That's number one. Number two, we usually have children who are just getting expanded, like sideways right, kind of left or right, think face left to right, not forward right. They're not. The expansion's not coming forward. We call that AP expansion. And with this AP expansion, we open up the airway when we bring the jaws forward, whether it's upper, lower, both, one, the other, whatever's needed. One, it's much easier to do in a younger child. And two, it opens the airway. So it's really important that you advocate for your child. And if someone tells you you're crazy or they tell you you're just over exaggerating, like just you stuck it off of social media. Like, I think, you know, social media is both a blessing and a curse. I think that one, it's given us a really beautiful platform to. In which to impart information as well as podcasts like this. But on the flip side, it also, you know, gives you like. It's like, who do I listen to? Who do I listen to? I'm sitting in front of this provider. I'm listening to this person on a podcast. This person's putting out information on social media, you know, videos and posts and all different things. It's hard. It is hard to know who to listen to. So I always tell people, feel free to reach out to me, and if, if I know somebody in your area, I will happily connect you with them. It's usually going to be a myofunctional therapist or a feeding therapist. And I'm going to say connect with them and, and see if they know these other providers that you should have a consult with. Because I'm much more in the know with individuals in my particular space than I am, let's say, like ents. And I do know a couple. But I do invite you, you know, at Hallie Balkan on Instagram, you're always welcome to message me and ask me if I know anybody, and I will happily connect you with somebody who, in your area who I think can help get you to the right person if that's not the person themselves. But the bottom line is don't give up. Don't give up. Early intervention is everything. We are literally changing the way that the child's face is growing. And if we don't intervene early, then the problem just kind of snowballs and it takes a lot more money and time and steps and interventions to get things back on track. Is it too late? It's never too late. Something can always be done. But again, the hoops you have to jump through, the steps you have to take, it does. It becomes a big investment, like I said, in time and money, especially the older that you get, right? Whether it's a teenage child, someone in their 20s, and we've even had individuals in their 50s, 60s, 70s, right? So it's never too late, but early is better. The other thing I want to say is just take a deep breath. There's a lot of information out there. And this is not to, you know, my goal is not to make anybody anxious, but rather to empower you with knowledge so that, you know, not to take no for an answer and you know, how best to work towards getting your child what they Need. Okay, so let's move on to the third commonly asked question, like, how do I help my child? They're so picky. I know they have a sensory motor feeding issue and they're cutting out more foods. Well, my first recommendation is going to be, if you don't already work with a feeding therapist, please, please, please set up an evaluation with a feeding therapist. Now, keep in mind that SLPs and OTs, we are only licensed. Where we're licensed, we can't treat you virtually all over the world. We generally, you know, there are some countries where we might need to have a license, but meaning, like for an slp, you know, in the US we might be able to treat there, but most countries do have a licensing process at this point and to this to date. So. And then within the United States, we can only treat where we are licensed. And if you exist in a space where we are not licensed, like, let's say that I'm licensed in Maryland and you live in California. Well, if I was licensed in Maryland and California, then I can see you. But if I'm only licensed in Maryland and you live in California, I can't see you over teletherapy. If you want to fly across the United States and come see me, then I can see you in Maryland. They make it really challenging. They're supposed to be making this easier for us. Supposedly. We'll see if that happens. But I say that because, again, we want to make sure that the person that you're going to is not just any SLP or ot. We want to make sure that they're trained in the proper things. So I always say sensory, motor feeding because there's. We have our sensory system and we have our motor system. We can't separate them. But a lot of people, a lot of courses train individuals as if we can separate these systems. And that's how people attempt to treat. And it doesn't work. It doesn't work. So we need people who are looking at it from a sensory motor perspective. And then it's also really awesome if that individual is trained in tethered oral tissues and also myofunctional therapy. Okay. Now, we talked earlier about the difference in. If the child's under four, cognitively, you're going to definitely want an SLP or OT with that training. If they're over the age of four, then you're definitely going to want, you know, you want somebody who's trained as a myofunctional therapist. If they're kind of a picky eater, you can also work with an rdh, but they're not necessarily going to address the picky eating or the spirit speech or anything like that. They're going to have to refer back to an SLP or OT for the feeding or an SLP for the speech. That said, sometimes the feeding starts to evolve and change as a result of a individualized program being put in place, a myofunctional therapy program. Okay? So just. Just know that. But from the picky eating standpoint, we have to look in the child's mouth. Okay? Even if it's a virtual evaluation, there is a. There are ways to obtain videos and images and have the child do certain things during the evaluation or have you do certain things that you video and send to the therapist that helps us see into the child's mouth, even if we can't get our hands on their face that day. Let's say it's a virtual eval. Right. The past couple years have made us really good at doing these. You want to make sure the person that you're working with is properly trained. Okay. And this is again, like feed the peds. My course is opening next week. This is this type of therapist you're looking for, especially for your birth to four, birth to five kiddos. I do have a website, pediatricfeedingtherapist.com that has graduates of my course. They haven't all put their information on there. I think to date, there's only like maybe 1200 or so. Just over 1200 of them in the United. Well, actually around the world, but primarily in the United States. So again, DM me at Hallie Balkan on Instagram, if you have questions about, you know, somebody in a particular area, because I have a whole network of graduates that I can reach out to who may not yet be on the website. All right, so then the other thing I want to say is meet your child where they're at. Okay? We want to expose them constantly to new foods and things. But what are they ready for today? You know, if they've had a really bad day, is today the day that we're going to expect them to eat a new food at dinner? No. And there's the other word, expect. Get rid of your expectations. Let them know you have no expectations. I'm just putting the food on the table. Okay? This is. This is actually funny because I'm sitting here. If you're watching on YouTube at a later date, once this episode is up, you're going to see me holding these foods. My daughter was in here playing. So now I'VE got all these plastic foods sitting here. I've got spaghetti and meatballs. I've got a donut. And she told me they were gluten free, in case anybody was wondering. I've got a cookie, also gluten free, according to her. I've got a waffle and I've got an egg and a chip and french fries and lettuce and onion and like just all these little play food that she brought me when she was, she was bringing me some food. Right? We have to think about a few things. One, what does a child like, right, Always have something on their plate that you know they like, that's kind of a safe food that you know they're going to eat no matter what else is on their plate? That is a go to safe, right? Number one. Number two, we don't want to have too many foods on the plate. It can be visually overwhelming, which means that the sensory system, our nervous system is going to go into like fight or flight. We're going to have these signals sent that kind of go, whoa, not today, not today, okay? And they're just going to shut down. And so any chance you may have had is totally out the window at this point. Right? So. So if they feel that we're forcing them or they feel pressured, what I'm saying is that nervous system goes into fight or flight. We want their nervous system to be at ease. We want them to be in what we call rest, rest and digest. We want them to kind of go, okay, yeah, I see that food on my plate. I don't really like it. I don't think I'm going to eat it today. But that's cool, right? They don't have to touch it, but the fact that they're not having a reaction to it, a negative reaction, and we're not seeing their body tense up. We're not seeing them turn their head away. We're not seeing them stick, scoop back in their chair or lean away from the food. They're actually still sitting there at the table in front of their plate with this new food that maybe once upon a time was really, really upsetting to them. That's a win. That is a big win. And so we have to think about how many little baby steps we need to take in getting them to the point where they feel comfortable trying a food. And we need to respond to the cues that we're seeing from them. That's basically where I'm going here. Again, remove all pressure and expectations. We don't force feed. We don't say, just take one more bite. Just one more bite. Just one more bite. If you eat three more bites, I'll give you chocolate for dessert. And I know if you try the broccoli, I'll give you iPad. If you do this, then we can go outside and play. We don't want to attach things, especially if you're going to let them do it anyways and they know they're going to get it anyways. We don't want to attach rewards like that to them trying something. Because what we're doing is we're basically saying, hey, you know what? I don't care that your body is screaming, oh, heck no. At this food in front of you. I'm going to force you to take a bite. And after I do that, then you can go do what you want to do, right? Then you can go have this reward. It's just, it's not ever going to lead to a child having a positive experience around that food and then that child going, you know what I think today, because they forced me to eat it yesterday, I think today I'm going to eat it. No. And if they do, it's going to be a learned experience with fear surrounding it. We're going to have negative emotions, negative thoughts, negative beliefs around food. They're going to be in fight or flight. Things are going to escalate easier, right? So we want to make sure that they are prepared. And so, you know, we say something in my house, we always say, we don't. I always say, don't yuck my yum. And my daughter, when she was like three or four, flipped it on me and she goes, don't yum my yuck. And I was like, well, there goes that phrase, because she just played me like I played her. And so it came to the thing where we had a conversation and I said, look, you know, when someone else is eating a food that they enjoy, they don't want someone else to sit here and say, that food's disgusting, that smells like socks, like, no, that's not fun for any of us. So we absolutely want to set, you know, expectations and rules around mealtime. But that's very different than saying, just take one more bite. Just take one more bite. If you take one more bite, then we're going to go do this, right? Because you're going to be saying that until the day they move out of your house. It's basically just going to end. Then once they do that, they're only going to end up eating the very limited selection. Probably that they want to eat anyway. So if you truly want to create a child who expands their palate and accepts a wider variety of foods, we have to remove all pressure, all expectations, and just continuously present it over and over and over again. We also want to introduce our sensory system to these foods in different ways. That could be a walk through the grocery store where they see the foods, but they're not expected to touch it. We're not going to talk about it. It's just around them. They're visually seeing it. Right. Then it could be a trip to the grocery store where they help pick up foods and put them in the cart, even if it's a food they don't eat. You could say, hey, do you want to pick out the red pepper? Hey, let's put it in this bag. Right. And then put it in the cart. And if they're kind of like, no, you could say, you want to see something really slowly that I do. And put a bag, like put one of the vegetable bags on your hands inside out and look. It's like a sock puppet. I'm going to go pick up a red pepper and then grab the red pepper with your hand. That's covered in the plastics. But now it's not skin to food. Right. Exposure. But they're still interacting with it in a way. And then next time, can we get them to pick up the food and put it in the basket or in the bag and put it in the basket. Right. Another thing you can do is if you're someone who shops online or the apps, when the food comes to your house. Well, one, back it up a step. Have them help you make the grocery list and pick out the foods on the app. Right. If it's like whole foods like I use, for example, I'm constantly having to go through and go, like, what do we need? What am I adding to cart for my last order? What else do we need? And I ask my kids, what do you want at the store? Right. Involve them in that, that process. If they're verbal and they're able to tell you, or they can point to a picture. Because these apps are really great for visual communication. And so they can, you know, they can look and then tactilely they can touch the food that they want you to put in the cart. So now they're part of that process. And then it's more exciting, like when the food arrives, have them help you unbag it or unload it and put it away. My kids love tasks. Like, it doesn't matter that it's food that they don't like. Well, really, my oldest. It doesn't matter that it's a food that she doesn't like and she wouldn't normally eat. She's going to pick that up and put it in because she enjoys helping, unloading the groceries. Who knew? And then if you want to take it one step further, actually interacting with the foods, you could do a cooking class. So this was something that, when I was homeschooling Lily, my now six and a half year old, during her kindergarten year, not this school year, but the year prior, I was like, I need. I need some things that are like, not mom, right? Like, I'm still. I'm still running two businesses. Like, I'm. I still need to, like, take care of the household. We're in a pandemic. I can't do all of this homeschooling myself. Joke was on me because she needed, like, full supervision for the cooking class, but that's fine. So I signed her for a cooking class, and this got her cooking things like meat and poultry and, you know, we had new vegetables. And I was not the one setting the recipes. I did pick the class based on the recipes that I wanted, like, that I thought would have good foods. Like, I wasn't going to do a baking one, because she likes baked goods like that. Like, sure, that could be fun for her. But we also bake at home. I was using this class both because it met certain requirements for the homeschooling goals and two, because it introduced her to some new foods that she would not interact with if it was just me and her. So she actually started trying the foods because she was interacting with them more, and she was the one preparing it. She didn't always like it. Like, she would take a bite into it and swallow it. She didn't spit it out. And she would say, well, I don't. I don't like it. It was okay. Like, okay, cool. Very cool. All right. And then the next time, you know, say, well, I didn't really like it that much last time. And I'm like, you did. You. You kind of liked it. You were like, I think, like, it wasn't your favorite thing. But, you know, sometimes it takes getting used to a food. So are you interested in maybe trying it again and seeing, like, does it taste the same as last time? Better than last time or some last time? Like, you know, we just. We talk about it, we have conversations around it. And I try not to guide the conversation or put words in her mouth, but I try to Just talk about the foods and make it a very easy conversation where there's like, no, like I said, no expectation attached. And if she says, no, I really don't want to. I'm not tasting that today. I'm not going to say, you have to, you made it. No, I'm not going to say that. I'm not going to say like, I bought it, it's on the table. That's what you're eating. That's just not something you're going to hear come out of my mouth. I'm going to say, okay, well then, what are you going to eat? Based on what's available for dinner tonight, here's what we're having. Here are the options. What are you going to like? What are you interested in eating tonight? Because I do try to provide her with opportunities to get her protein from foods like vegetables and eggs and things that I know she likes. But it's not always easy. And you don't want to always become a short order cook, making five different meals for everybody sitting at the table. Right? So we try to make one general meal and make sure that we have enough foods for her to eat that we know that she likes, but also have those newer foods to expose her to as well. So cooking classes can be phenomenal. And just interacting with the food, chopping veggies, putting them in the bowl if it touches their hand, but you know, they don't even, because they're interacting with it in a different way than you telling to pick it up and taste it or bring it to their lips. Sometimes it's like the sensory system is just chill. We're like, okay, I can do this, like, no problem. This is fun. And they don't realize, like, oh, I just, I just handled the food and put it in, you know, in the bowl. But it's another positive experience with that food, even though it never came anywhere near their face. And that is what we're trying to achieve. We're trying to increase the positive experiences that they have with foods. Watch their reactions, respond to them appropriately, and just make sure they feel safe at all times. Because if they feel safe and they trust you, they're going to experience more time and rest and digest. But if they think you're going to force them to try new food at every meal or try that new food that they didn't eat for lunch or dinner last night, or, you know, or bringing back the same food repeatedly and not mixing things up, they're going to constantly go into fight or flight before they even sit down at the table and before they even know what's on the dinner table because they're going to go, well, this is always a anxiety provoking situation. I'm not really, you know, I don't really want to eat dinner tonight because they're going to make me eat something I don't want to eat. Right. So we have to think about how we frame it and the experiences that we have surrounding it and try to make a lot of those experiences more positive, if you will. So hopefully that's helpful. Obviously I don't like to give like clinical therapeutic intervention type of strategies that may be happening in a session because I defer to the treating therapists. It's going to look different based on the child and the therapist and their training, what the child needs. It should all look very different. But if you're ever working with somebody where you feel like they're forcing your child to eat a food, please get a second opinion. I'm just going to leave it at that. All right, so we basically answered three of those biggest questions that I get. You know, how do I know if I need a myofunctional evaluation or if my child does, how do I help my child with airway issues and you know, what are some pointers basically for kids with picky eating or sensory motor feeding issues. So I hope this was helpful again if if you are an SLP or OT. FeedThePedes.com opens on May 23rd at 9am so join us in the next round of Feed the Peds where you can learn all things feeding tethered oral tissues myo for that birth to birth to 5 crowd. I look forward to seeing everybody there and I'll see the rest of you 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 @halibalkinbiz, on Instagram Alibulkin 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.