Episode 211: Differential Diagnosis: OMDs & PFDs

Hi and welcome to episode 211 of the Untethered Podcast. I'm your host, Holly Balkan and it's just us today. I wanted to answer a question that popped up in my current Feed the Peeds 12 week group. We were going through Module 8 where I teach all about orofacial myofunctional disorders and how that applies to our little ones, right? How it applies to birth to four, even five, before these kids are really ready to jump into traditional orofacial myofunctional therapy programs. Right? So this question came up and we're going to answer it in a minute, but I just want you to take a moment and remember that there are a lot of different diagnoses out there, right. And there are a lot of different ways that we can approach assessment and ways that we can approach treatment. But I think the most important question is who is a child or who is the patient? Who's the individual sitting in front of us? And not always get so caught up in the diagnoses it can be helpful. It's highly insurance driven. However, looking at a patient first and foremost is always our goal, regardless of where you work in the medical field. So on that note, we're going to jump in in a second. But real quick, if you are doing if you're listening to this prior to May 1st through 5th, 2023, I am posting the the five day training. It's completely free to screening your first pediatric feeding patient. Go to feedthepeds.com backslash training. You can learn more. You'll get five hours of, you know, completion on a certificate. A certificate of completion. I should say that you can track yourself. And then for those who end up joining the Feed the Peas 12 week course, we actually do give you an additional five hours of continuing ed for participation in that five day training. But if you don't join, you can always count those yourself. All right, so let's get started. Quick Disclaimer all information, content and material of this podcast are the opinions on 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 Untether Podcast. I am your host, Holly Balkan. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner 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, airway, tethered oral tissue and Pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest. Posture, tongue up, lips closed, teeth apart, breathe through your nose. Let's get started. All right, so going back to that initial question that I introduced before the intro and everything, how can we differentially diagnose orofacial myofunctional disorders and pediatric feeding disorders? Now, the question that actually came in, because I talk about this in Module 8 of Feed the Beads, the question that actually came in was surrounding how do we differentially diagnose orofacial myofunctional disorders from apraxia or childhood apraxia of speech or other forms of apraxia. Right. And typically with orofacial myofunctional disorders, we're looking at the face. So that question is really going to be more in tune with childhood apraxia of speech. And I thought that was a great question. And I do think some of this applies to that as well. I want to say first and foremost, more than one thing can coexist. More than one thing can be happening at a time. It's not that when we are looking to diagnose a child, again, heavily medically or insurance driven, I should say, it's not that we have to give them one diagnosis. If there's two that apply for a child, that's okay. However, I do think that we should not be labeling a child and this is out of scope. So this is just my opinion for this one. But we should not be giving them an ADHD diagnosis, ADD diagnosis, or other various behavioral types of diagnoses until we have ruled out an orofacial myofunctional disorder, which. And if you go for a myo eval, right, that's going to usually be your first step to other additional referrals or evaluations that may be necessary for those kids. Right? So it could be they go for a sleep study or they're going to an ENT or an allergist or wherever we're sending them to look at airway. Right? That is what has to happen. And I can't wait for the day when that's a requirement before one of those other diagnoses that I mentioned. Because if a kid is not able to breathe, they're not going to get restorative sleep. If they can't get restorative sleep. That's going to impair how they function during their waking hours, whether they're at home or school. And this can. You know, I'm not. The focus of today is I actually want to focus on OMDs and PFDs, pediatric feeding disorders. But I think this is worth mentioning in this discussion that we need to be making. We need to make sure we're taking a holistic approach to the child. And when I say holistic, I'm not talking like Eastern versus Western medicine here. I am talking. We look at the child as a whole human, just like we show with adults, too. That's a whole different conversation for another day. We have to look at the whole child. What is going on with this kiddo? What is happening at home? What is happening at daycare or school? If they're in daycare or school, what is happening in, you know, play dates? What's happening when they're in one environment versus another and with this person versus that person. Right. It goes beyond just how they physically look when they sit down in front of us. Because we can't help them improve the quality of life and their ability to function on a daily basis, then what's the point of what we're even doing? Right? So, all right, let's move. Let's move forward. Just some food for thought there. But, yes, we should be looking at the whole child. And that means head to toe. Right. Obviously, you stay in scope. But if you notice things that are like, ooh, yeah, okay, what we're seeing here on the face or in the mouth is also impacting other areas of the body or other arenas, you know, then it is highly appropriate to make a referral to someone who is skilled and. Or licensed to address some of these other concerns that you may want addressed. Right. Or that you may want assessed is probably a better. A better way to say it. Because we can only assess for or say that something is needed if it's actually in our scope. Right? We can't. Like an slp, for example, because I see this all the time. Cannot say that a child needs a frenectomy. Neither can an ibclc. Neither can an rdh. Neither. Right. But a dental provider can. Right? So we have to say an ENT can. Right. An md. So we have to think about, like, what we're seeing and then refer to the right people so that we can have conversations, work together, look at that whole child, and then proceed forward. All right? And again, this all applies to what we're about to talk about, because this question Just like, sent me down this. You know, I answered the question on our live case study call, and then I just. I remember thinking about it after, and then I thought about it a couple days later, and now we're like, I think two. About a week out or two weeks a week. We're just over a week out from having had that conversation at the time of this recording. And it has popped into my brain a lot. And I'm like, it is such a beautiful question to ask in trying to determine the best way to work with the child who needs us. Right. And help support that family or caregiver unit in also helping the child to optimally thrive and, you know, not just survive. Right. So like I said, the initial question came in and it was all about, how do we differentially diagnose OMDs and apraxia? But I'm going to focus on OMDs and pediatric feeding disorders primarily. I want. I want to narrow this one down specifically to the oral phase of the swallow. Why? Well, because when we're talking about orofacial myofunctional disorders, only that oral phase is involved. You know, we don't go. We don't go into the pharyngeal swallow. We don't go into the esophageal component of it either. We are strictly talking about what happens from the point of the food entering the mouth up until the point that the swallow begins. Right. Swallowing is not like the actual trigger of the swallow. And beyond that is not mayo. That is not mayo. Okay? So anything that basically happens inside the mouth prior to reaching the oropharynx. Excuse me. Is what we're focusing on. Okay? So here are my thoughts. When it comes to that differential diagnosis. I'm going to refer to them as OMDs for orofacial myofunctional disorders and PFDs for pediatric feeding disorders. Okay? OMDs and PFDs, again, primarily including the oral phase of that swallow. Now, it's also critical, in my professional opinion, that a child who presents with any sort of feeding challenges be assessed first and foremost by a speech language pathologist, an occupational therapist, or at times maybe a physical therapist who has specialized training in pediatric feeding MYO and tethered oral tissues. And I call this, like, the perfect trifecta. Sometimes I call it feeding with a twist of tots and myo. If you've been following me for a couple years, you've definitely heard me say feeding with a twist of tots and myo. So that's first and foremost. Second, we need to know some hallmark Symptoms, signs or symptoms of OMDs that may exacerbate a PFD. Okay. The MYO symptoms. The symptoms, you know, and signs and symptoms of the MYO disorders that may exacerbate the pediatric feeding disorder. Because newsflash, they can co occur and they often do. And this needs to be addressed in assessment and treatment. And again, that is going to be limited to the providers who can assess and treat pediatric feeding, because that's where this fall, that's the realm that this falls under. Especially in like the birth to four, maybe even up to five year old, cognitively intact, you know, crowd. Right. The, the chronological age here. The actual like, oh, you're 5 years old because you were born on a birth, on a date five years ago. That's not what I'm talking about. I'm talking about children who are cognitively intact. So they have a cognitive age of anywhere from birth to four or five years of age. Which means we may have older patients who are cognitively functioning at a lower level. They also are not appropriate to work with just anybody on an orofacial myofunctional disorder. Sorry, side rant. They need to be seen by a provider who has it in scope to work with pediatric feeding. Okay, so we'll just, we won't be, we won't belabor that one. Let's move on. But the three areas that often. There are three areas that I find that often get overlooked in the assessment of pediatric and treatment too of pediatric feeding disorders. So I'm going to kind of lay those out here. So in my professional opinion and from what I have seen and from being highly specialized in this space and like this, you know, realm of myo tots, peed feeding, you know, etc. To make a differential diagnosis and rule out an orofacial myofunctional disorder from these children who, you know, also present with pediatric feeding disorders, we need to consider the following. Okay. There's three things as I mentioned. So number one is upper airway issues. Right. A lot of SLPs OT, you know, you might be looking at the, the, you know, lower airway. Right. I'm talking about upper airway as it exists in the nasal cavity and the oral cavity. Okay. I could say maybe as far as the oropharynx, but again, that once you move into the pharynx, you kind of move out of the myo scope of practice. So those types of, you know, issues are typically not always addressed. It's, it's that, it's a. So there are soft tissue challenges that I'll talk about. And the third thing are hard tissue or dental challenges, which again, not a dentist, but I'm just going to share what I know and what I'm able to share. So in going through airway issues and specifically upper airway issues. Right. The lower part of the airway is often addressed. If we have a child who, you know, pediatric feeding, who we're talking like the lungs, Right. The trachea, we're talking about that. When I say lower airway issues, a lot of pediatric feeding therapists are very highly in the know when it comes to that type of information, but not so much with the upper airway. And so these signs and symptoms might include open mouth posture, mouth breathing, noisy or audible breathing, chronic congestion, snoring, sleep issues that are second to the airway. Right. So those are some things to look out for. The Next thing number two, as I mentioned, is soft tissue challenges. So most SLPs, OTs, PTs, RDH is dentists, ENTs, pediatricians are not trained to, to assess for the functional impact of tethered oral tissues like tongue, lip ties. I can say cheek ties, but that's not something that comes up a ton in my practice. It's more rare than the tongue and lip t. But these are. Right. Everyone has a frenulum or frena or frenula or whatever you want to call it. Everyone has that tissue. It depends one, how tight it is. But then two, is that impacting function? If function is impacted, that's when it becomes a soft tissue challenge. Right now we have a child who's struggling to feed. But is it a pediatric feeding disorder or is it a orofacial myofunction disorder? Well, it could be both and that's why it requires someone who's a pediatric feeding therapist. Additional soft tissue challenges may include your lips apart. Right. And so we may see mouth open. There could be drooling liquid loss when drinking. Right. Just a couple examples. And then we move into the third thing, hard tissue. Right. More of those dental type of challenges. When I say dental or hard tissue, I'm talking about crowding of the teeth. Yes, even the baby teeth. Baby teeth need to have spacing between them. They are not supposed to be on top of each other. They should not be turned in the lower central incisors. Your two little teeth at the bott should not be turned inward. Same thing goes for the top. Right. We should have relatively straight looking baby teeth that are all nicely spaced apart because that spacing is there for future adult teeth, your permanent teeth to come in and if that spacing is not there, guess what? That is a sure sign that you're going to have an issue with malocclusion. We're going to have teeth turning or coming in in different places because they just don't fit, right. Or we may see delayed eruption of teeth. My own children have had these types of issues, right. So my now 7 year old, when she first started to. We, I think her first two adult teeth were her lower central incisors and they were what we call shark teeth. Right. They were that row of teeth behind her baby teeth. And her baby teeth were just not moving and it was like, oh, okay. Well, those teeth just didn't really trigger the root of those two lower essential incisors, the baby teeth, to like start to die off and fall out to make room for those, you know, now new lower and permanent lower central incisors. And so, you know, it did, it did kind of work itself out over time. But we also had. She's been through expansion and we won't go into all that today. But we see these hard tissue dental challenges, you know, really lead to, like I said, malocclusion. We are seeing high narrow palates in a lot of babies. And a lot of this is at. Is. Is prevalent. It's not prevalent, but it is prevalent, but it's present at birth. Right. We may also see oral habits that impact dentition and, or the development of the jaw, upper and or lower the jaw Positioning the posturing, right? You suck your thumb, it brings your lower jaw forward. Why is it doing that? Well, could be twofold. One, we might be opening the airway by putting our thumb in to then kind of jut our jaw forward as a result of the positioning of our thumb. And two, we may be putting our tongue up in the upper palate, the hard palate, because our tongue's not up there. And so that thumb is filling a void that the tongue cannot, you know, that it's not, it's not doing its job. So thumbs like, hey, let me help you out, right? So obviously not obviously, but this is not an exhaustive list. It is just the tip of the iceberg. But in my opinion, these are some of the things that most frequently get overlooked in this age group. So next time that you have like an infant or a toddler who's struggling to breast or bottle feed, transition to solids, expand food repertoire, maybe they're going the other way and they're decreasing the foods that they will accept, they're not moving beyond the picky eater stage. Or, you know, or. Or maybe they even experience like impaired digestion or issues with elimination right bowel movements. They're highly uncomfortable. Put your MYO eyes on. We cannot properly treat pediatric feeding disorders, our PFDs, without ruling out our OMDs. And like I said, they typically co occur. So we need to integrate our treatments and work from this holistic lens. And again, I'm not telling you to go be crunchy if that's not you. What I'm telling you is like, look at the whole child sitting in front of you. What is going on with them. Look beyond just what you can see. Ask questions, dive deeper. Because it isn't until we understand the full impact of what's happening that we can truly help a patient. Patient. And that we can truly also help bring together the right team members in different specialties to then help that child. Because like I said, I call this pediatric feeding with a twist of tots and myo. And this is what I teach in modules seven and eight of Feed Pete's. So my mission, right, since July of 2019 remains. I want to uproot the current medical system. Big task. And I just really want to allow our children to move from survival mode to thriving and given the opportunity to function optimally. But first we have to, like, we need to get these little ones off wait lists. We have to help educate caregivers. We have to help educate professionals that are both in our space and in the, you know, in the medical spaces that surround the work that we do. Because only then will they know, like when. Like a parent, for example. Only then will they know when, how, and to whom to reach out to for help and a professional. Only then will they go, oh my gosh, you know what? This is what that that individual was telling me about. I think I should probably refer this kiddo for a eval. Only then can. Can patients can children start to get the help that they need if we, you know, so we have a big job, right? We have a big job. We need to go out there, we need to educate, and we need to make sure that this information is truly in the hands of parents and professionals that work with children. So I'm going to leave you with a simple question today, okay? Do you want your patients to survive or thrive? Okay. Because letting them survive is basically assessing and treating them, but also ignoring the impact of OMDs and tethered oral tissues, right? And just kind of going like, oh, yeah, well, I treat them for pediatric feeding. Well, that's good and great, but if you are not also Looking at them through the lens of the orofacial complex for upper airway like we talked about, Right. And the soft tissue that's really. And the hard tissue, you know, issues that I mentioned. If we're not looking at these things, then we're basically just saying, okay, I'm okay with my patient surviving. And that's fine because that might be what's comfortable for you right now, but it's not okay for your patient. I mean, it's okay if that's what you choose to do, but it's not okay for your patients, so you might as well refer them all out. And that may seem like really, really not nice and kind of mean, but we have way too much knowledge at our fingertips and we have tens of thousands of children who are going through the therapy, the interventions that they need, and we are seeing them all improve or seeing them not have to always fall back into therapy or getting stuck in therapy forever. Like when we're talking, you know, more of these OMD pediatric feeding disorder, oral phase type of presentations, like that's what I'm focusing on in this episode here. So obviously this can apply to our more medically complex kiddos too, that we work with in pediatric feeding. And we should absolutely be looking at all of these things with them as. But for all intents and purposes, do you want these children to survive, like I said, by ignoring OMDs and TOTs, or do you want them to thrive by assessing and treating through a more holistic, well rounded, highly educated, evidence based lens that considers that whole child and what they need to function optimally? I choose thrive. So what do you choose? I will hopefully see you guys if this is new to you or if you're just like, I need to go through that free training at go to feedthepedes.com backslash training and you can join me for the free five day training that I am doing May 1st through 5th, 2023. We have all the details you need on that feedthepedes.com backSlash training page. But you can always reach out to me and DM me with any questions and I look forward to seeing a whole bunch of you there. We have had over 14,700 SLPs and OTS go through that training. The first 10 times that I did it over the past three years. This will be the 11th time. I cannot promise how many more times I will be doing this training. At least not live. I don't know. I make no promises, but I'm definitely doing May 1st, doing it May 1st through 5th of 2023 this year and I would love for you to join me because I think just being armed with this knowledge, even if you don't want to work in this space, you need to know how to screen the peds right? You need to know how and where to and when to refer them. So I look forward to learning linking up with some of you there and I will chat with the rest of you on our next episode. Thanks for listening to this podcast. If you found value in this episode and want to hear more of these Myotots, Airway, and Feeding related episodes, be sure to leave a review on Apple Podcasts and share this episode on your social media platforms. You can access free resources and all I offer@halibalkin.com or pop over to Hollybulcan on Instagram to get all the latest updates.