Episode 227: Less Is More: Pediatric Feeding Exercises

Hi and welcome to episode 227 of the Untethered Podcast. Today it is your host, Hallie Balkan, and it's just me. And I wanted to do a short little series of answering frequently asked questions, especially those who are looking to get into the pediatric feeding space, but especially those who maybe have taken courses and are just not quite sure like how to proceed forward. There are some questions that we get very frequently and that is what we're going to dive into today.

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 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. So what are we going to talk about today? We are going to talk about a frequently asked question, something that comes up quite a bit and I think it's something that you know when you're a newer feeding therapist, right? Maybe you're not a new therapist per se, but you're newer to feeding therapy. It's something that I think it, you know, we always say, oh, it takes time. You need experience, trust the process, you know, keep your head in the material and kind of follow the process that we've set forth for you. Like at least in, in, you know, our 12 week feed the Beads. But one of the questions that comes up a lot besides not understanding, like what different types of palates look like or what chewing patterns look like, which we have done a really great job of demonstrating inside the Feed the Pete's course because we don't get those questions anymore. But one of the questions that we get, and I just had a conversation with somebody about this today, which is actually what prompted me to go, you know what, this question gets asked a lot. And I went and looked Back at our database, I'm like, yep, we definitely have had people asking this question in the past. So what is the question? The question is, how do I know what baby needs what exercise? Or how do I know how many repetitions to do of an exercise or how do I know if I have enough exercises? Right. And the thing that I want to say when it comes to pediatric feeding therapy, and we're talking like infants and toddlers, is less is more, less is more. And you hear me talk a lot about holistic approaches too, right? We need a holistic approach, meaning there are going to be other providers oftentimes that come into play, whether we're referring because we have concerns about allergies or airway, or referring because we feel like there's tension somewhere in the body that needs to be addressed. And I'm not going to dive down into like all the different tension patterns. That's not my area of expertise. I should be, I will be bringing somebody on in the near future who can talk to more of that from their area of expertise. But what I want to dive into is how do we know what exercises to use? How many exercises do we need per session, per baby per issue, and then like, how many repetitions do we do of each exercise? So this won't be a very long episode because hopefully this is a simple yet not simple answer. Right. It does take experience getting your hands on as many infant and toddler faces in their mouths as you possibly can. Okay, that's definitely a step one. Why? Well, because we need to know what typical feels like. What are normal fat pads feel like, what does, what do even masseter muscles feel like? You know, the muscle that goes between your upper and lower jaw, your mandible and axilla. Right. What, what is a strained or under development overdeveloped or underdeveloped mentalis? Right. These are things that we often talk about in the myo world, but I don't hear it discussed a lot in when it comes to INF toddlers. And this is why I talk about these things. This is a very little small piece of what we talk about in the tethered oral tissue and the myo modules inside of feed the peds. But I spend time talking about this because I find that others don't. And I think that that's where so much confusion lies. Right. So I can't sit here and give you a protocol and say every single baby needs to go on step one, step two, step three. And they each need three to five repetitions of each exercise. And if they have a problem with their jaw, do this and a problem with their cheeks, do that. Right? Because that's work for every child. But to. On that same token, that is why, like in Feed the Peace, for example, we do give ex. We give exercises. Now, are you going to come in and get a library of 100 exercises? No. And you don't want that. Believe me, you don't want that. What you do want to learn about are the exercises that will help from an oral motor standpoint, a sensory. Oral motor standpoint, right? Because we talk about how you cannot separate sensory from motor. Right? There maybe different systems within the body, but they're all intertwined, especially in how it, how we function as humans. So trying to treat one system and not treat the other doesn't actually make sense yet. That's how so many feeding courses approach it. But anywho, that's a whole conversation for another day. The point is, what we need to know is we need to understand the direction that the muscles go. We need to understand if, like, let's say that the lips, like the baby, comes to us and the baby's lips are tense, the upper lip is tight and curling in. Well, why can we relax it? Can we relax the orbicularis oris, that muscle that surrounds the lips? Can we relax the muscles between the base of the nose and the top of the lip? Are there things that we can do? Yes, we absolutely can. And so those are the kinds of things that we're teaching inside the course so that we're able to go, okay, but the lips, it's not just the lips, right? What, what it appears to be on the outside externally is not always what's going on. Right. This may be a compensation of something else grander. So let's say the lips are tight. Well, let's look at the cheeks, okay? And if the cheeks are tight or the cheeks are underdeveloped or whatever may be going on. Well, let's look at the jaw, okay? The jaw is kind of, you know, we backing it up a minute. The jaw is a foundation for everything else, Right. So if our jaw is not stable, we've got sliding, gliding, whatever may be going on with the jaw, if it's not stable, then our foundation for everything else in our orofacial complex or from an oral motor standpoint, you know, internally, within our mouth, if you will. Right. And on our face are our muscles that support feeding, swallowing, you know, speech. Closed lips so that we can nasal breathe, all the above, right. If that, if something's impacted we have to kind of go one step further to figure out, like, okay, well, the lips are impacted, but maybe that's because the cheeks are impacted. The cheeks are impactable, but maybe that's because the jaw is sliding all over the place. And, okay, if the jaw is unstable, like, how do we start to work with this baby? To make sure. Or toddler, right. To make sure that we are developing the right muscles. Right. And then there's always the conversation of tone. We have to then look at, well, is the child hypertonic? Do they. Are they hypotonic? Low tone? Are they. Is their tone. Does their tone appear to be kind of somewhere in the middle? Like, is it pretty typical? Because if we have a low tone child, we're going to want to definitely work on strength to help support that lower tonicity that we're seeing throughout, you know? And so there's a lot of different conversations that come into play. And I know I'm jumping around here, but the point is, the reason why I want to talk about this is because I think we're so conditioned to believe that, oh, someone just gives me a hierarchy of step one, step two, step three, step four, step five, and then says, okay, on step one, you're going to do these three exercises, and then on step two, you're going to do this exercise, and on step three, do these two exercises. Exercises and stuff for. That's not how it works. That is not how it works. Now, I will tell you, we are developing a certification, right, for pediatric feeding. And one of the courses that we are developing is a framework, but it's a framework to help guide. It's not a definitive framework that says, step one, do this, step two, do that. And I know this is probably kind of elusive. It's a little bit like, okay, Holly, what are you talking about? And that's as much as I'm going to share right now, because one of the clinicians on my team, who is phenomenal, but who is one of the mentors and course creators inside the certification we're developing, it's like her, like, framework that she's kind of developed based on working with lots of patients, medically complex, tethered oral tissue, you know, all different kinds of patients over the years. And so I do think it's helpful to have, like, a framework. But I want to encourage you to create a framework in your mind that kind of goes, okay, what is the jaw doing? Great. Okay, that's our foundation. The jaw is not stable. Well, let's look at the cheeks. Let's look at the lips, let's look at the tongue. Right. Let's look at the, the face, let's look at the shoulders, the neck. Right. So I know as SLPs, you know, we don't typically treat anything below neck level as far as feeding and everything goes, we always say, like, we're like neck up, ot tend to be, you know, the torso, the cor. And then a lot of our PTs are the limbs, the arms and legs. Right. That's kind of just like the dumbed down version of basically demonstrating, like, who works on what. However, we know that there's definitely some crossover because, you know, SLPs treat esophageal dysphagia and other feeding issues and swallowing issues, and that goes beyond the neck, you know, and then we also have obviously pts and ots who can treat things inside the mouth and on the face too. So that doesn't totally hold true, but you get my point. So going back to this question that was asked, that's sending me on all kinds of tangents, what I want to encourage again is, as I mentioned, the jaws are foundation. Right. And then we kind of look at everything else and how it's integrating. We do know that by 18 months of age, we should have lingual, jaw, lip, tongue dissociation. Okay, so mandibular. Right. Lingual and labial dissociation. What does that mean? The jaw has to be stable in order for that to happen. The tongue and the lips also need to be strong enough. They need to have enough range of motion. If we have tethered oral tissues, that is likely going to be impacted as far as range of motion goes. And so if at 18 months of age, we're supposed to have a tongue that can work separate from the jaw and the lips, and we're supposed to have lips that work in, you know, separate from the jaw and the tongue, and a jaw that can kind of work, separate, you know, move on its own without the tongue always following it and. Or the lips following it. Right. Like, what do I mean by that? Well, if you open the mouth that the tongue just lays on the floor of the mouth. That's not what we want to see. If we open the mouth, the tongue should be up. Right? If we open the mouth, the tongue may be sucked into the palate or the tip of the tongue may be up, you know, behind the upper essential incisors or upper front teeth. So this is the same thing as saying, you know, oh, let's see if a child, an older child, can make like a kissy face. Right. Being able to isolate your lips from your tongue and your jaw is a skill that's hard for a lot of the kids that we work with. And so that is somewhere where I like to start looking, even on younger kiddos, to see, like, what is happening. Is the tongue working with the jaw as one unit when they're a young infant? Like, it's supposed to. The jaw is there to support the tongue, or are we kind of like all over the place? Does the tongue have full range of motion? Or when they go to move their tongue, does the entire jaw shift left or shift right with the tongue? Right. These are things that lead to jaw sliding and gliding. And we start to see these little ones who have a really hard time managing feeds, a really hard time transitioning to solids, a really hard time sleeping with their mouth closed, breathing through their nose, a really hard time developing speech sounds. And then they get labeled with speech sound disorders, and they end up in years and years and years and years of speech therapy, because not everybody knows how to address this properly. So when it comes to determining if a child has enough exercises assigned to them, that's not necessarily the question we should be asking, Right? The question we should be asking is, what are this child's strengths? What are their weaknesses? Do they have the dissociation, the mandibular labial lingual dissociation by, like, 18 months that we're talking about, amongst other skills. You know, if you go to. If you download the free screener that I offer, the pediatric feeding screening packet and checklist and everything, then you will find. Find a whole host of symptoms and everything. You know, signs and symptoms you can check off, but you're also going to find the speeding development chart. And if you're watching on YouTube, I'm holding it up for you to look at right now. It's actually an old. This is an older version, but still. Still the same as far as milestones go. The colors are just different. But you start to see that the jaw, the lips, the tongue, right, they all have individual skills and milestones that we're supposed to achieve as we move through. As we move through development. And if one thing is off, right, if that jaw is not engaging in a munch chew, but it's just kind of mashing food up. The tongue's just mashing food up against the palate. Well, the jaw is not doing what it's supposed to do in that munch chew is supposed to be there around, you know, six months of age when we introduce solids, right before that, it's a phasic bite, which is reflexive, but that's a different conversation. So we also need to look at the lips, and if they can do their job, do they seal? Do they, you know, are they actively moving on their own? Are they starting to work separately from the tongue and cheeks and even our palate? Because early on, the lips are supposed to work as one unit, as I've mentioned, right? The lips work as one unit with the tongue, the cheeks, and even the palate. Okay. But our tongue, with the support of our cheeks and our lips and the jaw, early on, needs to be able to cup. Right? For breast and bottle feeding. Then, you know, around three to six months, the tongue should be able to protrude out of the mouth and retract, pull back in. Right? So these are types of skills and things that you'll see in the milestone chart. And I'm not going to go through the whole thing, but you get the point, right? There's certain skills that we need to have, and when you understand what those skills are that we develop between birth and 36 months of age, the question doesn't become, how many exercises do I need to give them? What are those exercises and how many reps do they need? The question become, okay, what skills do they have on this developmental chart? What skills do they not have? Did they kind of. Did they get some earlier ones and then skip over one and jump ahead? And they appear to be chewing with an early rotary chew. Except how are they doing that? Because they don't really retract their tongue properly and they're not lateralizing enough. How are they doing this rotary? You know, how does it appear they're doing a rotary chew without lateralization of the tongue? Well, we see this sometimes, right? So we have to be able to look in the mouth. We have to be able to look at the face and understand what's going on. Because eyes can be deceiving. What you see on the outside can be deceiving. We need to figure out what's going on on the inside. Okay. And that's where we start to go. Oh, well, if they're not lateralizing their tongue, what can I do to encourage lateralization? Okay, if I stroke, like, the inside of the cheek, does that do anything? If I stroke the gums on the other side, on the side that I want them to lateralize to, does the tongue move over to where my finger is, you know, kind of stroking the top of the gums? If that's not working, and we have a child who's you know, introduced solids, and we add taste into the mouth. On the other side, does the tongue follow? If we put the spoon on one side, does the tongue follow? You know, there's all different things that we can do to trial and see what's happening and things that we can do to encourage these natural, you know, oral motor movements as well. So again, it becomes less about what exercise do they need and more about stopping and thinking about what is the goal? What skill are we trying to develop and how can we help them get there in a functional way? Right. These are all functional skills that we need to work on. So are there exercises? Absolutely. But I will tell you that a lot of the exercises, especially intraorally and even on the outside of the face, tend to be more of, like, massaging the muscle and the direction of the muscle kind of helping to relax things, sometimes helping to encourage tongue cupping and sucking, especially in our little ones. And then when we move forward into working with transition to solids, we want them to be able to use their lipstick, clear spoon. We want them to be able to move food over, you know, to their molars with their tongue. We want to be able to chomp, chomp, chomp to those foods and make sure that they're doing, you know, they're. They can move the food back on the tongue to the back molars without gagging. Right. So these are all the things. And I think if we run, there's more goals than I've mentioned. But if we start to think about, again, what is the end goal, what is our functional goal here? Then we can start to think about, okay, what can we do to help this child achieve that? And I think if we get out of our heads and we stop worrying about, like, how many. How many exercises should I assign for homework and. And how many reps and how many this and how many that, and we go, okay, you know what? This tired. Like, let's see if we're just working on biting, right? I love tools, especially for our kiddos that are, like, on sensory overload. They see food and they just shut down. Right. You're not. They're not having it. Not in their early sessions with you, at least. Right. So we pull out some tools. If we use these tools and we can have them bite on a bite block. And let's say in the session, they bite three times and then they fatigue. Well, guess what? Their goal to work on that at home may be three to five, because we know they fatigue at three, and I'd love them to do five. Right. That's how I'm picking how many reps I want. You know, if they're able to do 10 without fatiguing, I'm probably not going to assign more than that because they're little. But I may still want them to work on 10 so that we can continue to work up towards, you know, the. It's more than just strength, right? We are working on these neuromuscular patterns and we have to teach them what the pattern is that we want them to use. So if they're stuck in munch mode and munch, munch, munch, and we're supposed to have moved kind of beyond a munch to like around nine months to more of a diagonal chew and then eventually into a circular rotary chew by three years of age, big jump there. But it does develop typically between like 9 or 12 months of age and 36 months of age to a more adult, like Rotary 2. Towards the end of that 36 months, what we want to keep in mind is like, what is that goal, right? Like what are we working towards? And if they're stuck in this munch pattern which so many of our 3 year olds and 4 year olds and 5 year olds are stuck in a munch, munch, munch. Okay, why, why are we stuck there? How do we break out of that? And can we teach them how to bite? Can we use a tool or even food, if they're open to it, to teach them where to, you know, where do we bite? In the mouth to teach them how the tongue moves around the mouth, right? So we want a circle in the mouth. We want a circular rotary too. And we do something like a five point bite where you put a chewy tube in on the back molars and you move it about a third of the way up and then you move it to the front between, you know, between the front teeth. You go a third of the way back or halfway back and then a third to halfway back and then you go on the back molars and you're kind of teaching them this like movement of, okay, this is how we move our tongue from one side to the other. And now let's go back and move it back to the other side. When we start to do these types of exercises, it starts to teach them, oh, this is what I'm supposed to be doing when I chew. And this is where my tongue is supposed to go. And the tongue starts to follow what you're doing. That's the goal, right? We want that motion, that movement that is going to develop into that circular rotary Pattern for chewing. Just like we want that movement for lateralization. Just like we want the lips to be working individually and not completely dependent on this whole process. Process. Right. We want the lips closed or chewing. Typically they're not going to be while you're working on something and maybe putting a tool in the mouth to work on this. But then the end goal would to be doing, would be doing that with lips closed. Right. So and truly, like chewing with lips close is like a two and a half year old, I'll be generous up to three year old skill. They have improved lip closure by like 12 months compared to before that. But truly. Or they're not chewing with their lips closed until like, like maybe about two and a half years of age. And like I said, we'll be generous and give them to three. So I think again when you look at the free packet that I have the and I'll share the URL to that in a moment as soon as I remember it, it's peed feeding screening.com if you go to ped feedingscreening.com that'll take you there. It's like I need to think about what it is. Anyways, if you go there and you look at the milestone chart, you're going to see everything that I'm talking about right now and we're going to dive into like a deeper conversation and training for free around this, the week of August. Want to see 21st through 25th. So if this is something that interests you and if you're kind of like, okay, Holly, like this is good and great. I'm still kind of confused. I'm, you know, I know that there's lots of people who use exercises. Yeah. And exercises are great. But if they're using exercises, they need to be able to explain what they're using, why they're using it, what it's helping with. Right. That's the why. Like what the end goal is so that we can tell like a caregiver, for example. Oh, hey, you know what? I'm putting my finger on the tongue. I'm encouraging the tongue to cup around my finger and then I'm going to draw it slowly out because I want them to try and pull my tongue back, my finger back in to work on sucking, you know. And these are the kinds of exercises that we, we do talk about in feed the peds. We do give exercises and we do share with you what we feel are some of the most critical exerc. But less is more. Right. We don't want to be sending These parents off with like a laundry list of exercises. I think that most often in feeding sessions like I typically will only give two to three exercises to a family. That's it. Because guess what? If you give them more, they don't do it. It's very rare when you get someone who does. Especially with new mamas who are exhausted, they're healing, they've got a baby who won't feed. The last thing they want to do is getting be getting in their kids mouth all day, every day doing all these different like exerc sizes when they don't have the capacity. But if you do a couple things and they start to see improvement, they're going to be more likely to want to work on more. Right. And then you can change it up if you need to. We don't always change it up week to week. We need to see how baby's doing because our goal is to build strength and stamina and make sure that they can adequately come into a feeding experience and have success. Whether that's breastfeeding, bottle feeding, solid feeding. Right. So hopefully this is helpful. I try to give you my whole perspective on less is more as well as using the skills that you're trying to build as the guidepost, if you will, for what you should be working on and what exercise may be most appropriate. But also in terms of repetitions, what can that child do right now? What? And you know, can we go one step beyond that for homework? And when I say one step, I mean like one extra rep. When we're talking about infants and even toddlers, three to five is usually plenty. Ten is a lot. But if they'll do it, do it right. And that's really what it comes down to is kind of figuring out who that child is sitting in front of you and what the family can handle. But also like I said, less is more. And therapy can be very successful with a small set of exercises because it's again, we want to think back to the function and the end goal and what we're trying to achieve and not give them like three exercises to work on this muscle and two exercises to work on that muscle. We're losing sight of what they need in feeding therapy when our brain just automatically goes there. And I share this too, because I'm guilty of that. I thought early on that that's like what we needed. And then I started working with these kids and I was like, oh, we did a small set of exercises in our therapy session today and we did a lot of repetition and they did really Great. And the family's going to carry out for homework. But I also at that had spent a lot of time figuring out how do I get to the root of what's going on? Why am I. Why did lips look the way they do? Why do the cheeks look the way they do? Right. So thinking about the root, what is leading to whatever compens, Compensatory patterns we might be seeing and what else may be leading to the presentation of, like, how they are in their feeding presentation today. And then that's. That's really how we tackle it and how we address things. So I'm always open to hearing other perspectives. I would love, if anybody has a differing opinion, free to reach out and share that with me. You know, we can talk about it on the podcast. You can come on and talk about it if you have a differing of an opinion. But this has been my experience. This is very reflective of what we teach inside pete, the PE where, like I said, we do give you exercises, we do show you how to do them, we do tell you what, tell them, tell you what they're for. But occasionally we get someone who feels like it doesn't seem like enough or a lot or I'm not sure. And I'm like, less is more, more. Less is more. Give it a try. Give it a try and see what happens. That said, we do have some amazing Feed the PETE alumni who are offering to share recordings of evaluations and treatment sessions, and we are uploading those to a bonus library for all current and past Feed the PETE students. So I'm really excited about that because I think it's very cool to see more than just us and to have access to seeing somebody else do an evaluation. And, you know, even the collaborative evaluations, we've got one of those that's coming up with a OT and a PT together. We're going to add that to the library. We've got one from an OT where the mom was actually an slp, the mom of the infant being assessed. And so some really cool opportunities to record some evaluations and to record some treatment sessions and to share this with everybody so that you can start to see that one. It looks different right from one one provider to the next. But also, even when we're asking the same questions or, you know, on the eval or the intake, and we're kind of piecing everything together, we have different styles. And also, things don't always go as planned. We want you guys to see that too. So anywho, I share that because I'm really excited about it. It's something that we're working on right now to roll it out hopefully in the next month. But yeah, so like I said, if you have any questions about the free training, the screening packet that I mentioned is peed screening peed feeding screening.com and then the free training is at feedthepeds.com backslash training. Either way, you know you can get added to the wait list for Feed the Peds on either of those, either the free training or the pediatric feeding screening packet. So yay, it starts soon. We're going to open the course again as I mentioned, or maybe I didn't mention it yet, but we're going to open it the end of August around August 28th for five days only. So so be sure to join us if you're interested because it's the last time we're doing it this year and we have not set our 2024 dates officially yet, so I can't tell you when the next one is. We only do it three times per year, but it's going to be at least five months from the time of this that this episode airs before we open another Feed the Peds course, since we're doing it end of August. All right, I will talk to you guys all in the next episode. Thanks for hanging.

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