Episode 178: The Impact of TOTs on Transition to Solids

Hi and welcome to episode 178 of the Untethered Podcast. This is your host, Hallie Balkan and we are going to talk specifically about how tethered oral tissues, tongue tie, lip tie, cheek ties can impact the transition to solid foods for our infants and even some toddlers. So let's jump on in.

Quick disclaimer. All information, content and material of this podcast are the opinions, updates of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm a certified orofacial myologist, feeding specialist and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses.

Let's get started. Okay, so this is going to be a short, sweet, to the point kind of episode. Today we're doing a little series of answering some questions, single question episodes, because we get a lot of questions around certain topics. And so we wanted to focus in on some episodes that would be both beneficial to providers and parents of infants and toddlers so that you know why you may be seeing some symptoms that you may be seeing, or why you've tried certain things that maybe are not working or just, you know, how to get to the root cause of what may be going on with, with your little one. So what does that look like? Well, as far as today's topic goes, how tethered oral tissues affect the transition to solids. I think we need to talk about a few things. The first thing being the American Academy of Pediatrics. Right. The aap. The AAP says that for most children, solid foods can be introduced in any order with the exception of honey, which should not be introduced until 12 months of age, but in any order, starting around six months of age, eating a variety of foods by seven to eight months of age. So is that a hard, fast rule? You know, in. In the history of guidelines from the aap, we have gone back and forth between four months as an intro to solid, six months. And then there's pediatricians who recommend anywhere in between. Right. The bottom line is we want to look for certain readiness factors. And what do I mean by that? Right. What are quote, unquote, readiness factors? Well, there are things like making sure that when it comes time for solid food introduction, we have certain oral motor skills in place, and I'm going to go over what those are. We also want to have certain gross motor skills in place. I'll go over a few of those. Right? And then we want to kind of take a step back and go, hey, if we've started to introduce solids and it's not going so well, and we believe there may be tethered oral tissues at play, or we're just not sure. Well, let's talk about the impact of those tethered oral tissues so that we know if it is something worth exploring. We know if those readiness factors may be delayed for a certain reason. Maybe it's a result of tethered oral tissues. Right, so. So let's jump into that. So what are some of the oral motor skills that we would like to see in place prior to introducing solids? I'm going to break it down by the jaw, the lips and the tongue. Okay. So for example, with the jaw, we have this phasic bite. It's a reflex, right? It kind of just. If you put your finger on the baby's future molar area, right on the gum line of their future molars and you push down, you're going to get some sort of a reaction. Typically, the baby may bite down or start to kind of engage in an up, down chewing action. This like phasic bite, okay. That will integrate into a munch chew, which is no longer a reflex, but it's now a volitional, intentional up down movement of the jaw and chew. Okay? So that's one thing we look for as far as the lips go. We start to see active lip movements emerge. Maybe that involves some rounding of the lips. Maybe we see baby smiling, we see the lips moving, we see active lip movements. Then with the tongue, the tongue is able to, at this point, when a child is ready, protrude and retract, right? Stick out and pull back and it begins to lateralize, or in other words, move side to side in the mouth as we introduce those solids. So we're really looking to see that the jaws developing into this intentional munch chew. The lips are starting to actively engage more. Right. Because we need lips to figure out, oh, hey, I need to close around that spot spoon and that food bolus, right, that bit of food on the spoon. And I need to clear that spoon. I don't want the child chomping down and, you know, hanging on really tight with the jaw. No, we want the lips to activate and help to clear that spoon. Now obviously this doesn't happen the first time you put a spoon in the baby's mouth or the first time if you're doing some mixture of feeding the baby and self feeding or baby led weaning or whatever you want to call it. I kind of like a, a hybrid of the two. I believe that as adults we eat and I know I'm diverting here, but as adults we eat purees, we eat liquids, we eat solids of various types. Children need to be exposed to all of that as well, right? So there's nothing wrong with feeding a baby puree and a spoon, especially in the initial interaction. We want the sensory system to be familiar with receiving certain types of input. But we also never want to force. And if the child is pushing away, has a grimace on their face, they turn their head, they pull back in their chair, they vomit, they gag, right? We kind of might just go, oh, okay, let's, let's take a step back. It doesn't mean we stop, right? But we have to recognize that there are certain cues available to us that we want to attend to. And maybe we have the child play in messy play on the high chair, we put some puree on there, some little mashable, you know, solids on there and just let them go to town. Maybe they end up pulling their hand up and wiping it across their face or putting their fingers in their mouth and they get a taste that way, right? This, these are all, and this is not meant to be a feeding therapy training by any standpoint, but what I'm telling you is all of these different types of interactions with foods, with solid foods helps the child's oral motor and sensory system or sensory oral motor system. Because truly we can't treat them in silos. We can't treat them as two separate entities. They really have a lot of interaction and overlap that we need to acknowledge. They are both equally important in this process. And so a combination of purees and other salt and solids, you know, a combination of self feeding and you know, parent leading the way, you do you right, you do what feels best for you. But watch your child, watch what they do. We want to make sure that in what we are offering, we are helping them and we are not limiting them in their experiences or further causing an aversion. Okay? And I'm not saying you're going to do that. I just want to make sure that, you know, we've seen children for example, who are only spoon fed and they've created this massive aversion to anybody else feeding Them and they only eat certain types of foods and they only eat on certain types of spoons and so on and so forth. Right. I'm not saying that was caused by the parent, but if we get stuck in a rut with a child who is already very limited in what they will accept early on, and they don't allow you to expand, they're not interested in expanding beyond those initial purees on a spoon fed by a certain person or, you know, whatever the case may be. Or maybe there's children who only want to self feed, but they only eat certain things. They're very limited in their foods and they don't want anybody coming near their mouth. These are all different signals that we want an assessment. We want to look at what is going on. We want to look at where the breakdown is occurring. As far as their oral motor skills go. If there's a breakdown occurring so that we can get in there and we can support them, maybe there's something happening at the level of the sensory system. Maybe they're in fight or flight. The second they see the high chair, the. That's not going to be a great experience for them. So how do we bring them back to a state of homeostasis? How do we give them what they need from a sensory oral motor standpoint to be successful to enjoy foods, to want to expand their food repertoire to feel safe while feeding? Right. These are all things that really come into play with making sure that a child is ready and those readiness factors are present when you introduce solids. And this is the kind of thing that is not discussed oftentimes we hear a parent say, oh, we had the, you know, five month checkup, the four month checkup, the six month checkup. And they just said, go ahead and start solids. Okay, that's great. But is the baby ready? Right. Is the child ready? Now, from a gross motor standpoint, we want a baby to be able to hold themselves up. Right? We want them sitting up even if they're in a tripod supporting themselves a bit, you know, okay, fine, but ideally, if they're sitting up by their, on their own, right. That would be even better. Or if they are in a harness, in a high chair or a chair of some sort that assists them. We still need them to be able to hold their head, their neck, their, their trunk in the correct upright position to support feeding. Right. We need them in an appropriate high chair or a seat for feeding as well. So these are just some things to think about and consider from a gross motor standpoint. Because if they're not yet sitting up on their own and you buckle them into a high chair and they've got on this, you know, this, maybe it's a five point harness and their head is kind of falling to the side or falling forward and that's not safe. We need to figure out a way to better support this child and figure out if they truly are ready for solids and if the team decides, yes, they are, well, what does that situ, what does that seating need to look like? What supports need to be added to make this a safe experience for the child. Okay, so then let's go into what, what is the impact on, of tether dural tissues on all of this? Well, we may see a delay in some of these readiness factors as a result of tegadural tissues that cause, you know, tension throughout the body and that often starts in the mouth. I said it in the last episode. You probably, if you followed me for a while, you've heard me say it throughout many different episodes. We are literally connected from the tip of our tongue to the tip of our toes. Our fascia is connected. If you look up fascia trains, it is a textbook. There's a beautiful image you can Google where you can, you can see the literal connection of fascia from the tongue to the toes. And we need to understand that the import, the reason why it's important to understand this topic is because our health starts in our mouth and the whole feeding journey starts in the mouth. Right. And so if, if we are truly connected and then let's say we have a tight frenulum under the tongue that could wreak havoc on the system at large. That could wreak havoc beyond just what's going on in the mouth. Okay. I also want to add the tongue may protrude really well. It may stick out right, maybe even too effectively sometimes, but maybe the tongue has a hard time retracting, pulling back to accept a spoon with solids, whether that's presented by the parent or the child is self feeding. And so sometimes we'll see the tongue pushing that utensil or the food or that loaded utensil right out, like forward and out of the mouth. And sometimes parents will say, oh, they don't like it. They have an aversion, you know, and they'll start to get nervous about what they're seeing. It may not be that they have an aversion, it may not be that they don't like it. This is, this is just the state of their anatomy at the moment and it's causing this physiological response because one, that's what the tongue may be doing. It may just be going maybe sitting low and forward. And when it goes to accept food off a spoon, it's learning how to do that. And maybe it's pushing the spoon and the. That bolus on the spoon just right on out, right? That could be one possibility. There could be many possibilities. But the point is that tethered oral tissues, right? A tongue that is tethered, like let's talk about tongue tie, specifically, a tongue that is tethered to the floor of the mouth may not be able to lateralize or move sideways from one side of the mouth to the other, right? One molar area to the other molar area or future molar area site. That's a problem. We need to be able to move our bolus. We need to be able to move that piece of food where it needs to go so that we can chew it even with a solid that can very easily be broken down with just saliva, with barely any chewing or no chewing at all. We typically don't just put it on the center of the tongue and smash it against the top of our mouth, right? That's mashing or tongue smashing, right? We often will take that. Food will go in, and even if it doesn't really have to be prepared, it may be moved over and lateralized and then brought back to the center of the tongue. So we need to look at what is going on with the bolus. And what's very fascinating is you will get infants between 6 to 12 months of age who quickly learn they cannot move their tongue to get the food there. And that doesn't feel safe. That doesn't feel good. So. So what they do, because the human brain and body is just an amazing thing, is they take their fingers and they push the food over to the molar area. They are literally helping themselves move the food to where they need to munch it and mash it to, you know, break it down and swallow it back. So if we see this, if we see a child with their hands constantly in their mouth, like placing food, we need to go, why? Why are they doing that? Right? Why do they hate using a spoon? Why do they hate using utensils in general? Even if they're fully in control, right? What is that like? Do they allow us to go in their mouth? Are they having a big reaction to us touching their face, their lips? If we put on gloves on our hands, do they have a reaction to those gloved hands, or is it not until we touch the face or we Maybe go in the mouth and try to, you know, feel under the tongue or lift the tongue up. What is going on? What is their response? What is their reaction? Because that can also be very, very telling. Now, obviously, if you go. If you put a baby on their back, their head on your knee, you know, on your lap, and you're sitting knee to knee with a parent, you're going in and elevating their tongue, a lot of babies are going to cry. That's the reality. We're doing, you know, we're looking for the frenulum and trying to see what it. What its appearance is, to see if it matches with the function that we're seeing an issue with. That's not what I'm talking about. But if you come near a child and you've built rapport, this child trusts you. I'm not talking day one. Okay? You really need to spend some time with them and build rapport. They trust you. They let you do all kinds of things in sessions. Like, they're fine with you putting food on their plate and playing in the food, and they'll even play in the food. And maybe they've made some progress and, you know, towards goals and whatnot. But you start to move toward their lips to just touch the lip or to engage in some type of an oral motor exercise or maybe some, you know, myofascial release or massage or anything, and they just lose their mind. This kind of makes us go, huh? Why are we having such a big reaction? Like, what's going on with the nervous system? What's going on with the sensory system? What's going on right now that. What's causing the child to have this reaction? Because babies aren't bad. Babies aren't challenging, babies aren't difficult. All these labels that people attach to babies, it drives me up a wall. No, babies are just babies don't make it mean anything else. They are just babies. Do they develop personalities? Absolutely. Are they human? 100%. But babies don't sit there and plot all day. Like, how can I piss my parents off at dinner? Oh, yeah, yeah. I'm just not gonna eat tonight. Yep. No, I'm gonna spit the food back in their face. I mean, look, they get playful. They'll do things with you, but they don't go on food strikes to piss you off. They don't vomit on a food tray to piss you off. They don't have a hysterical meltdown to piss you off. Right. Babies are responding to their environment, and they're also responding to what's going on internally and they can't vocalize that to us. So if we see, I keep calling these big reactions, but if we see these big reactions or certain body language or, you know, responses from the child, we need to pay attention. We absolutely need to pay attention and we need to go, what does that mean? And if we can't figure that out, that's when it's a great time to call in somebody who might be able to help you, like an SLP or an OT or PT trained in pediatric feeding, who can come in and, you know, take a comprehensive look and see are we on track or are there some things that we might want to work on. Right. So the other thing I want to mention, going back to a tongue that is tethered to the floor, is if that's the case, we may not be able to lateralize and move the food from one side of the mouth or feature molar site to the other. Right. This especially becomes an issue as we move beyond just purees, which for many children is the first couple weeks of feeding, if not day one. Right. Depending on the approach and what's what the parent is using and pursuing as their methodology for solid introduction. So we need to consider that this is a, this is a big problem, but we can absolutely address it. We just have to know how to assess and treat. We have to know how to address it. And it doesn't need to be complex, but it does need to be addressed. Now the other thing I will say is that in this very, this is very common, we see this a lot. The oroficial complex is just often not functioning as it should be as a whole. Right. And there's oral motor skills that are maybe delayed or compensations present as a result. Right. So we're already seeing these compensations really early on and some children may compensate really well while others really struggle. So again, comparing your child to milestones or to other children, not always the easiest or best approach. Look at your child and if they are struggling and you are struggling or you are stressed out about the situation and evaluation can never hurt, it can always help. It doesn't tie anybody to therapy. And sometimes we, we do evals and we say, hey, you know what, you're doing awesome. I see exactly what you're saying. Here are some things to try at home. Call us back if you feel like this is not progressing. Right. Or let's check back in in three months when you know, we'd expect X, Y and Z. We are doing a free five day pediatric feeding screening training. If you go to feedthepedes.com backslash training, you can get all the information it is coming up and you will get five hours, five free hours, I should say, on a certificate. If you have questions about that, feel free to DM me. Otherwise, check out feedthepedes.com backslash/training that will be taking place during the week of September 12th through 16th, 2022. And just to go back and sort of wrap this up, you know, other areas can impact. I didn't talk so much about, you know, a labial tie or buckle ties, but a labial tie, for example, can impact feeding as well. If we have a really tight upper lip, for example, because of a tight lip tie, or it could be lower, it could be the lower lip as well, you know, and it's really retracted and we have that gummy smile. You know, we don't always see really big gummy smiles on infants that we tend to see them as they continue to develop. But if that, if that little lip is really tight and rolling inwards and we're having a hard time kind of flipping the lip, even for breast or bottle feeding and then obviously for spoon feeding, solid feedings, we will see ongoing issues. My own child, for example, had a really hard time learning how to drink from a open. She managed the straw just fine, but the open cup, she could not figure out how to do it because of the place of her lip frenulum. And it just, it was very fascinating to watch her try to figure it out. It didn't matter how many times we showed her, she just didn't quite get it. Hers actually was we did not release her lip, but we released her tongue. And she did figure it out after her tongue tie was released, which was fascinating because I was convinced it was her lip. And I share that because. Because we don't always know where exactly dysfunction may be stemming from. We may have an idea. And so I want to caution you, and I will also say cheek ties can impact the function of the cheeks as well as far as feeding goes. But moving on, I want to caution you, we don't want to just race into a release. We need to prep a child for that. That is a whole other episode. We have done episodes. The importance of pre op therapy on post op therap. And I just want to let you know, as both a provider and or parent of an infant or toddler who may be struggling with solid feeds or if you work with this population, it is imperative. And yes, we see a massive difference in the children who receive pre OP care with the feeding therapist. If they're breastfeeding, that ibclc, CLC should definitely be involved. If they are, you know, if we're noticing tension throughout the body, any, you know, what's the word? I'm thinking of asymmetry. You know, we want to get them to somebody who does, who works on the body, an infant provider who works on the body. That might be a chiropractor, that might be a craniosacral therapist or an osteopath. But we need somebody who is going to understand why we're referring them. They'll be able to collaborate with us and they're going to help to reduce tension and get the body, you know, in a symmetrical shape, if you will. Basically bringing the body back to a state of homeostasis so that the body is just as prepped as the mouth is that, you know, that we're working on for that release. And then we need to continue that after the, the release as well. So again, that's a whole another topic for another day. But I always like to kind of put that plug in there because everyone goes, oh my gosh, my child has a tongue tie or lip t. I got to go get it released today. Let me find a provider who will do it now. Not always the best solution. We want to make sure we prep that body just like we were. If you were going into any other type of surgery, we would be doing some pre op, we would be talking about the post op therapeutic intervention as well because it's. That tongue is really important and has a big job. So if you just release a tongue and expect it to miraculously start working the next day for breastfeeding, bottle feeding, whatever the case may be, I'm going to tell you, in most cases that doesn't happen. It's always an exception to the, to the norm, to the rule, to whatever you want to call it. But in most cases that doesn't happen. And sometimes feeding gets worse for 24 to 48 hours, you know, maybe even a week before it starts to improve. And so we also need to consider the health of the child, their weight, any other factors, and make sure that we have the wiggle room, move towards a release knowing that they may be uncomfortable and they may go on a hunger strike for a day or two and hey, there's nothing we can do about that, right? So this is why it's so imperative to have that initial evaluation to work with a team to figure out what is the specific treatment plan for your infant or toddler or that infant and toddler on your caseload, so that we are not just jumping in blindly and negatively impacting these children's futures and presumably causing more harm than good and leading to more compensations rather than improving them and bringing the child back to full function. So. Or to a place of full function. Right. So with that neuromuscular, you know, re education that we engage in, in pediatric feeding therapy, SLPs, OTS, you know, some PTs that do infant toddler feeding, we need to have a good grasp on what we're working on and why we're working on it. And so I'm going to go ahead and wrap up there, but I just want everybody to remember that, you know, regardless of exactly which point a child is introduced to solids, we need to make sure they have those oral motor skills, you know, in place and evolving, those gross motor skills in place and evolving and a lot of other skills are then built off of that foundation. So it's really critical that we have that in place. And if there is, if there are tethered oral tissues at play, we need to have an evaluation. We need to know our baseline, we need to know what we're working with, what the functional impact of those tethered oral tissues are and you know, what the individualized treatment plan is that may be most appropriate for the infant or toddler in front of us. So I hope that's helpful. This was meant to be a really quick one today everybody. Have a great day and we will be back here talking about more. We could do some more of these mini episodes. I will request that everybody just submit to me at halibalkin on Instagram, just let me know what do you want to hear? What big questions do you have? And we will choose some of the really common questions and continue to answer some of them in these shorter hyper focused episodes. Because we think that it's really, really important to get this information out there to the masses. So I will go ahead and wr wrap up and just say again, if you are a speech language pathologist or occupational therapist, we have a free five day training coming up September 12th through 16th, 2022. You'll get five free hours on a certificate of completion. Go to feedthepedes.com backslash training and you will learn in those five days with me how to screen your first pediatric feeding patient. And don't worry, you don't need your own patients if you don't have them yet. You will be using mine. So I can't wait to see you all there. And I will I'll talk to you all next week back here on the podcast.

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