Episode 228: Functional Pediatric Feeding Assessments

Foreign. Welcome to episode 228 of the Untethered Podcast. Today it's your host, Hallie, and we are answering another frequently asked question and topic of discussion that comes up quite a bit and that is what is a functional assessment when it comes to pediatric feeding? And how do I know if a provider is doing a functional assessment? So this will be a really good episode for you. Whether you're a clinician, you know, some sort of professional working in this space and or if you are a parent. You probably want to listen to this too. All right, let's dive in.

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, 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 knows.

Let's get started.

Okay, so this question, right? What is a functional assessment? Especially as it pertains to pediatric feeding assessments. I want to dive into that a bit, but this comes with a. With a bit of a disclaimer because this is a term where I really didn't hear a lot of people calling it a functional assessment until the past couple of years. We've talked about this for a long time now. However, just because somebody says they're doing a functional assessment does not mean they're doing a functional assessment. So let's figure out the very basics of what a functional assessment looks like. In short, before I dive into a little bit more information, a functional assessment looks at function. What do I mean by that? Well, there's structure and there's function, and we do want to look at both, right? Don't get me wrong, we'll talk about that. But function means how. How are we functioning in daily life? How are these muscles functioning to meet the needs, the basic needs of this Individual, right? What do we need to live? We need to be able to breathe, and we need, you know, nutrition. Right? We need to be able to eat. So how. And the amazing thing is that when you're an SLP and. Or a pediatric feeding therapist or myofunctional therapist, like SLP ots, for example, who work on feeding but also can work on airway, now we're. We're double whammy, right? We've got the ability to assess whether or not whatever we find in our assessment is impacting the ability to breathe through the nose, right? Is it impacting the tongue's ability to rest on the palate with lips closed? Because that's correct oral rest, posture for breathing purposes. And then our second basic need is eating. Is what we're finding in our evaluation impacting this child's ability to form a bolus, Manage a bolus if it's a liquid, you know, swallow, like, what's going on, right? So the two basic needs in life are very critical things that we are addressing through a pediatric feeding evaluation. And if you're not, then what are you even doing? Right? I hate to say it like that, but it's true. So we call it a functional, like oral motor feeding evaluation or assessment because we gotta look at function. What is the reason that most parents come to us to help their child? Oh, my child is falling asleep at breast or bottle. My child is not growing on the weight charts. My child is really uncomfortable. Crying, screaming, arching their back, you know, just. They just look so uncomfortable, so unhappy after every feed, you know, or. Okay, well, we're having a hard time transitioning from liquid feeds, as in, you know, infant in the first six months of life, to solids or. Well, my child is, you know, we get a lot of. My child's a picky eater. They only eat, I don't know, 20 foods, 15 foods, 10 foods, five foods, right? So now we've got a problem because we're either on a limited, limited amount of foods that we will consume, or we are cutting foods out. And when you get to a small number of foods and children start to food jag, which means they kind of like things that they always ate, they don't longer eat, and they're kind of jagging back and forth. We got a problem, right? We got a bigger problem at play. And so it drives me a little bit crazy that there are courses out there and instructors that only teach to, like, the sensory system when it comes to feeding, or that only teach to oral motor skills when it comes to Feeding. Because as I mentioned in the prior episode, as you probably heard me say before, feeding is a sensory, sensory, oral, motor experience. It is a full body experience. It is very complex. We cannot treat or truly even assess, in a. In a sense, the sensory system separate from the motor system. They are so intertwined that we have to be looking at both. We have to consider them an assessment. We have to consider how what we're finding is impacting function and, you know, in daily life, eating, breathing, everything we've mentioned. And so then we have to kind of figure out, like, how are we going to get them working together to move forward and help this child and get everything back on track, or get it on track for the first time, if you will. Now, the one thing I will say is I was actually having a conversation with a colleague who's in the Feed the Pete's course right now, and we. This is kind of what prompted this conversation. And, you know, really great question was asked about, like, well, what do I. What do I do, like, with these parents who come to us because, like, their child is really picky and they want to. They want to work on food expansion and everything. And my initial response to that question is typically somewhere around the lines of, we have to educate on the fact that children are picky for a reason and they become, quote, unquote, problem feeders, according to some people, for a reason. What is this reason? Oftentimes it's safety. It's the body's way of saying, this is not safe. I had a bad experience or I can't manage that food you're giving me. Maybe the gag reflex is too far up in the mouth still. Maybe they have tetheral tissues. Maybe they can't lateralize their tongue and move the food over to their molars to chew it. Maybe they, you know, kind of get stuck and then the taste is not so good. Maybe they can't chew it properly and they can't break it down and it's scratching up their palate. Now, the top of their mouth hurts from eating a scratchy food that they couldn't properly chew and break down. And when they tried to mash it against the top of their mouth, it didn't go so well. You know, there's so many different examples and reasons and everything that these things can happen. But when a child is having difficulty eating or feeding, it's super stressful. And I think the thing that we need to remember, whether you're a parent or you're a provider working with parents, is we need to Show a little grace in these situations. This is really stressful. If you remember, I just told you that breathing and eating are our two basic necessities in life, right? And so when a child is having trouble eating and then maybe their breathing is impacted too, because we have cases like that, this is like everybody's on high alert. Everybody is extremely stressed out, right. And part of what needs to happen is we need to hear our, the, you know, the caregivers out. If their goal is food expansion, we want to work with them. We want to make sure that we address that. We also need to do our job and educate on how, if we work on the functional skills, we address the sensory oral motor system through a very strategic means. And they feel safer. They're going to be more, the child's going to be more willing to try new foods, more interested in trying new foods. We're not going to have to always ask them. We can maybe just put some things in front of them and maybe they don't gag in response to it anymore. Maybe they talk, tolerate it being on the table. There's that sensory system at play, right? But that's also the sensory systems at play now because that child system is saying, oh, hey, you have oral motor skills not to do that. So like, we're good, eat it or don't eat it. But like, we're fine, we don't need a gag anymore. Maybe we move that gag further back, right. So there's this interplay between sensory and motor and we have to make sure that the approach we're taking and the assessments that we complete are functional. Okay, so what does that, what does this even look like? Basically like my practice has a couple therapists or more than a couple therapists, but I have a couple full time therapists, I should say, and then a larger team of part time therapists who assess and treat pediatric feeding disorders. And when we evaluate functional feeding skills, one of the biggest things, as I mentioned before, is that we are supporting families with a number of different things. It can be, it can be complex. Even if the feeding challenge itself is not super complex. Just navigating this with caregivers and, you know, helping the child and keeping the child calm and keeping the caregivers calm so the child stays calm during feeds. That's, that's probably one of our biggest challenges at times. So during our assessments, Right. There's a lot of education that happens, but we're also going to be completing a evaluation of the oral motor sensory skills. As I was mentioning before, we're going to look at the developmental feeding skills. So in my free pediatric feeding screening packet, there is a chart. If you're watching this on YouTube, I'm going to. Sorry for that noise. You're going to see me hold. This is an old version of the chart up, but it's all the same skills, just different colors. You're going to get this feeding development milestone chart, if you will. And it breaks down both the gross motor, fine motor and then oral motor skills, which I think is really cool to see it all lined up together. But we look at those developmental feeding skills because we should basically develop all these skills between birth and 36 months of age. And if we don't, and the child's now three and a half four, four and a half five and they don't have some of those foundational skills that they really should have developed by age 3, 3 to kind of carry forward in life, well, we got to go back and look at that, right? We got to address that. So we're going to look at those developmental feeding skills. We're also, you know, going to look at how they swallow. Now in children who have greater swallowing concerns and need a swallow study, that's different, we're going to refer out for that because we are a home, you know, based practice and we do not provide swallow studies anyways. And then we're going to also engage the child in some more like play based activities because we work with a lot of infants and toddlers and just, you know, we're going to have a little meal with them, you know, or at minimum a snack because we want to see them chew, we want to see them swallow. How do you, how do you even assess that without seeing it? Right. And so like when I do my feeding screenings, I have them have a quick little snack, a little cracker and a little drink of water from a Dixie cup because I just, I need a little glimpse into what's going on. We do a larger meal or snack in our evaluation so that we can see how the child manages the whole experience, if you will, from start to finish, but also just, you know, to watch their skills and what they're able and capable of doing. Right now we do have parents use their own foods because we want it to be familiar foods. Now I don't want to come in and evaluate a child for the first time and provide random foods to a child who's struggling with eating and or swallowing. Right? Like that's, that's probably not going to go over so well. So aside from the fact that like we want the most natural environment and most realistic type of information and setting and all that fun stuff. Let's also just make sure that it's valid. Let's make sure that we also don't send this child into total fight or flight the first time they meet us. We need to gain their trust. We need to build rapport. So let's give them their favorite foods, and, you know, we'll guide families on, like, different types of foods that we want them to have, like, a crunchy food and a. Maybe a pure puree and maybe, you know, in a liquid. And we'll have, say, tell them, you know, make sure that there's a spoon for the puree. And it could be. It could be a yogurt, it could be an applesauce, right? Maybe we have for the. The crunchy one, it could be a pretzel stick. Then we want to have, like, a more meltable type of, you know, food, which could be something like veggie sticks and so on and so forth, right? If the child is older and we have, we're able to use smaller, smaller little pieces of food. Like, I love with my. My, like, preschoolers, I might do little raisins, because, oh, my gosh, raisins are the crazies. Watch a preschooler eat if they have feeding challenges. I will give you, like, one story. So I had this kiddo that I was assessing, and every time this child put the raisin on the. In their mouth, they actually placed it on their back molar, but they could not seem to, like, get it off the back molars. And so they kept chasing, like, themselves, like, turning their head towards their shoulder to try and chew this food. And it was like this very interesting movement. I said, huh? And this was early on, after I took, like, one of my first myofunctional therapy courses. And I was kind of like, huh, this is fascinating. Like, why is this happening? And obviously lack of dissociation between the jaw, the lips, the tongue, the cheeks, the palate, you know, all the things. But it just really opened up my eyes. And after that, I started giving raisins when. When appropriate to children to see what they would do. And some of them just take a whole handful, stuff it in half, chew it, and then swallow it. And we're like, oof, that doesn't look like it felt so good. And then other times, we have kids who eat one at a time. And again, one of the things that I constantly found was if a child has trouble with, like, dissociation of the jaw from the lips and the tongue especially. I would note that they really struggled with a raisin because it's tiny, so it's hard to manage, and it's chewy, so we've got that chewy texture in there too. So anyways, I wanted to share that because I think it's very fascinating. But also when you start to do a lot of these evaluations, you start to notice what foods can be really great and really helpful in giving you some really key information pretty quickly. So if they only take a bite or two and then they're done, you're probably okay. So anyways, we like the families, though, to bring preferred foods that the child. We know the child accepts, and we don't typically get into foods the child refuses to eat in an evaluation. Occasionally we might say, you know what, have a food that your child used to eat that they don't eat anymore, so it's least from familiar to them. But then we can also, like, have the parent present that at the end. So if the child, like, is done, melt is kind of like, I'm melting. I'm not doing this. You just brought out a food I don't like anymore. You know, it's the absolute. And the evaluation can end. But we do like to present that to see how the child responds. What is their response pattern? What do they do when they're presented with something they don't like? What happens? Do they completely shut down? Do they have a meltdown? Do they gag? Right? What does that look like? Because that's. That's information that's very helpful to know. We want to see what's happening so that we can help them. We want this to be functional. If we don't know how they react, how do we help them? If we don't know that certain foods trigger certain things for them, how do we help them? Right? So it needs to be functional in the sense that you're gathering information so that you can then go back and go, okay, the child does this when this is presented, the child does that. When foods like this are presented, the child, you know, then we can kind of go, okay, we're also. We also assess the oral motor skills, right? The sensory. Oral motor skills. And we looked at the developmental, you know, skills that we expect for a child their age. And now we have an idea of why those behaviors, quote, unquote, behaviors, I don't love that term when it comes to feeding. But we won't qualify them as good or bad. They're just behaviors. Now we know why the child is Behaving or reacting a certain way. Right now we have an answer. Now we have a way forward. So the other thing that we may ask parents to do, too, is bring preferred utensils. If there's a fork, a spoon, you know, a little grabber or something that they use to eat with. For our kiddos that are on solids. Love when a family brings their own utensils, maybe even their own little bowls instead of eating out of, like, a pouch or something, unless that's what they normally do. I want to see that too. The goal is to get a variety of, like, textures, even flavors, you know, which we can provide if necessary. But again, I just love when it's something from the child's home that they're familiar with. And then, you know, if the child's just like, I'm not hungry. I refuse to eat. That's okay. Back off. Put the food away. Like, remove it from the visual field. Remove it from the room so that you cannot smell it, see it, hear it, taste it, any of the above, right? And we don't want to interact with it anymore if the kid is like, nope, take it away. Move on. Especially if you have other things left to do in your evaluation. And don't worry about bringing it back until you've built some rapport with that child. And this could be a couple sessions in. If you do it early on, I would just say, let's have a snack together. What kind of snack do you want to have? And maybe present, like, two options that the family knows the child loves. So you start to gain some more information into what that child likes. This is even what we do in our evaluations. We just call it snack time. Hey, let's take a break and have a snack. Are you hungry? What do you like? What do you like to eat? Oh, yeah. Okay, cool. Let's see what mom brought today. Right? Let's see what dad brought today. Let's see what we've got in there. Okay, let's take it out and put it out in front of us. Hey, let's, like, eat for, like, a couple minutes, and then we can play a game. What game do you want to play? Right. Then divert their attention away from the food so they start to eat. But we. The attention is not all on them. Knowing that you're watching them eating, right? That's not functional. People don't sit there and stare you down while you eat. I mean, maybe they do sometimes. That's strange. My kids get really angry if they feel like someone's staring at them. When they're eating at the dinner table. So I get it. But we want to divert their attention just as if they were at a restaurant or a play date or. Or preschool or daycare or whatever. Right. So that the attention, again, is not all on their eating and the food. Okay. That's going to allow for more natural information. And if you want to record that, like, on a video camera, great idea. So that you're not having to sit there trying to, like, write everything down and paid really close attention. Because at that point, your goal should really be interacting with the child while the camera's kind of capturing everything for you to go back and review later, especially if you're a new clinician. But even seasoned clinicians like to record evaluations and certain parts of evaluations so that they can review this kind of data later. What else can I tell you? We will sometimes tell families, like, don't eat a big meal before you come, so your child's hungry, so they'll eat with us. But, you know, kids are kids, and that only works out so well sometimes. Or before we come to them, I should say, because we go to them, they don't come to us in my practice. And then we also encourage, like, you know, any family member that. Or caregiver that's present to participate too, just as they may normally participate, especially in, like, a snack time. You know, obviously they're going to be the reporter on a lot of the questions and parts of the evaluation. But in terms of actual, like, snack time and, you know, observing the child, the caregiver can be present, especially if that seems to calm the child down. Sometimes we have kids who get really angsty because they may think that food comes out and a parent's going to kind of force them to eat. And if you start to see that, you can say, oh, hey, mom, do you want to go take a walk and get some water? We have, like, some water down the hall. But I would explain this to parents ahead of time. That way you can see how the child does without the parent. And again, it's going to depend on if the child separates well from the parent or not. If you can even do something like this, this may be something that happens further down the line. But I share this because this all goes back to function. We're trying to do this because we want a functional idea of how the child reacts. So if they are having a certain reaction with one parent present versus another, or a caregiver versus another, that's helpful information, too, because we need these skills that we are going to work on to improve not just across environments, but across individuals, different individuals in different environments. Right. Otherwise, what's even the point? Right. We need to generalize outside of our feeding therapy sessions. So then that really allows us to kind of go, okay, we see what's going on here, we see some patterns or we know what we need to work on. Here's some recommendations of, like, next step things. And, you know, we write up our report and everything, and then obviously we'll make any referrals as we feel necessary. So some of the signs and symptoms, well, I'll leave you with that today. But some of the signs and symptoms that tell me a child may benefit from, like a functional feeding evaluation is that, like, I've talked about a little bit already, they're gagging with certain types of foods or textures or tastes or even temperatures. Maybe they have a very limited number of foods as we talked about earlier on in the episode. They may just kind of like refuse entire food groups or certain colors of food or certain, you know, categories of foods or textures. Poor weight gain is definitely on the list. It's not number one, but it's one of the reasons that a lot of pediatricians will refer. And it's a lot. It's also one of those things that I think once the weight does get low or their child's falling off the growth charts, parents get really, really, really, really worried. Rightly so. But, you know, we can. We can typically get things back on track if you come to us early enough and not when you're a week away from a feeding tube. No shame in, you know, in that game, if that. That's what you want to do. But I have had a parent, basically, you know, I had this one parent who kept saying, like, oh, well, they don't place feeding tubes until babies are like 12 months of age. So, like, we have time. And the child was six months. I was like, no, no, no. I spoke to the hospital and the doctors, you know, the doctors at the hospital, I should say, I spoke to them. They want to put a G tube in your child next week. But I encourage them that you are going to work with our team and that you are working really hard to try and avoid that next week. No promises, but let's see what we can do. Right? So all kinds of interesting conversations around feeding and beliefs, and sometimes we hear things the way we want to hear them, and sometimes we only remember a third of the information that we did hear, even if it's accurate. Anywho, when it Comes to poor weight gain, right. We obviously have less wiggle room if a child's lower weight and lower on the weight curve and they're not thriving. You know, if there's failure to thrive or they're really just kind of very fatigued, you know, there's. They're not getting proper nutrition. And this has been going, been going on for a while. You know, that's definitely something to consider. And poor weight gain is going to be a big, big, big factor. You know, I had a kiddo who was first percentile her whole first year of life and then jumped up to fifth percentile. And she's still like petite and tiny, right? So it was not something that they were super worried about. They said, ah, she's on her own growth curve, she's fine. And I was like, I can't feed my child. She's not fine. It was more about the functional impact on both her and I when an infant into toddlerhood as well than the actual poor weight gain itself. So little, little information there. If it takes the child a long time to eat, like longer than 20 to 30 minutes to eat a meal, that's definitely a sign you want to get things checked out because they may be fatiguing. If they're fatiguing, it may seem like they're. They're eating a lot over a long period of time, but they actually may be eating less over a long period of time and expending more calories and trying to feed, in which case they're not really taking in enough to sustain that in their rest of their daily activities. Taking longer than 20 to 30 minutes to eat can be a really good indicator that we need to like, see what's going on here, right? If they have difficulty chewing or swallowing foods, if they're. I mentioned the gagging before. A lot of parents will call and say, oh, my child's choking. It's actually more rare. It's usually gagging. Now, obviously there are children who choke as well, but choking is one. Like you can't breathe, you can't speak, you start turning, your skin starts turning a different color. Like you go through, you start becoming. Coming blue or purple. Like that's not good, right? Your airway is blocked. That is true choking, whereas gagging is, you know, you can hear it, it's audible. They may be coughing, they may be making noise, they may be crying, scream. You know, something may be happening because they've had this reaction that scared them and kind of threw their body into fight or flight. But that's very different than choking. I always like to give that little, that little tidbit and then difficulty transitioning from like if they are on a feeding tube, like a G tube or similar to oral feeds. Right. Taking food in through their mouth, the oral cavity. So that would be another really great opportunity to have a functional feeding evaluation. Now you should have probably had one if before a any type of food was placed in unless the child was really, really young and it was kind of a critical medical decision in the moment and it just kind of had to be done for other medical reasons. But some point a functional feeding evaluation should absolutely take place. If not before, soon after, you know we have any type of feeding tubes in place or considered as mentioned. Okay, so this was supposed to be a really quick episode, so I'm going to wrap it up here, but I hope this is helpful. I wanted to really dive into what a functional evaluation is. Kind of like a little glimpse into what that looks like and then how you know if a child needs one. And this is a, like I said, a great, great episode. Whether you are a medical provider, clinician or a parent of a child and you're just not sure. So as always, if you have questions on this, reach out to me. You can DM me on Instagram at Hally Balkan. Always happy to point you in the right direction and when possible connect you with therapists in your area. Just know that the we have over 1800 SLPs and OTS that have graduated from our Feed the Pete's course and many of them have have not all of them, but many of them have put their their bios and their contact information so you can reach them based on location on pediatricfeedingtherapist.com our directory of graduates from Feed the Peds. So definitely check that out. If you're looking for a feeding therapist, you're looking for a feeding therapist to refer to. We direct people there every day and that's that. Hope this is helpful. Again, reach out to me at Hally Balkan on Instagram if you cannot find somebody in your in your area on pediatricfeedingtherapist.com and that's that's all. I'll leave you with that today and I will chat with you all next week.

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@halliebalkin.com or pop over to Hollybulcken on Instagram to get all the latest updates.