Episode 276: TOTs, Food Aversions & The Nervous System with Hallie Bulkin

Hello friends, and welcome to episode 276 of the Untethered Podcast. Today we are going to talk about tethered oral tissues and food aversions. We'll probably dive a little into the sensory system, you know, the nervous system, all that good stuff. This episode was totally inspired by a Instagram Live that I was just a guest on and I wanted to bring it here to the podcast because I think there was so much good information discussed. So get ready, we're going to dive deep into this 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, 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, tetradural 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. Foreign. Okay, so where do we even begin? I think that there are some gaps in knowledge when it comes to understanding the connection between things like the sensory system and, you know, kids who get the title of sensory processing disorder, and not necessarily title, but I would argue it's more of a symptom. It's not an official diagnosis in the icd, Sensory processing disorder, but it's a very real thing, right? It is a real, very real thing that, that people experience and children experience. Children that we're working with. Right. And so between that and ultimately, like where we see it come into play with tethered oral tissues, that's where I want to focus. Because there is definitely an impact of tethered oral tissues on feeding, on eating. And I do think that this is a conversation that we need to dive into. So when a child is tongue tied, right, the tongue will struggle to move food around the oral cavity, around the mouth effectively for chewing, for prepping that bolus to be swallowed. Right. And this can lead to things like picky eating, problem eating you know, refusal of certain textures or temperatures or food colors or, you know, we see certain patterns, right? Can also, we may see, like. Can also, we may see. Okay, I can't talk, but like, reflecting on my lovely thought processes that unfolds here, other symptoms that we might see. You know, we may see gagging, we may see the child pushing food out of their mouth. We may even see some pocketing of food in the cheeks, like, you know, kind of like the chipmunk cheeks, right? But basically, the restricted tongue movement affects oral motor function, and it makes it a challenge for children to eat. So what is the big problem here? Well, one of the big rules of thumb that I have and that I talk to my team about and that I teach on is we need to make sure that a child is not living or living in fight or flight 24 7. We need them in rest and digest mode. Right? So what is fight or flight? Basically, fight or flight is the sympathetic nervous system, right? It's, you know, if we have a car, right, that sympathetic nervous system, when it goes into fight or flight, it. It acts like the gas pedal is like being, you know, pushed down real fast, right? It triggers an actual physiological change or changes, I should say, in the body. And so, like, if we're faced with a threat, if we're faced with danger, our body is going to activate this fight or flight response. And it's a survival mechanism. It's going to prepare us to either confront whatever that threat is in, in front of us, like that fight side of it, or escape from it. Flight, right? Fight or flight. That's where we get the fight or flight from. What are those physiological changes? Well, our heart rate increases, our blood pressure increases, we have a boost in energy because of the adrenaline, right. That's released. There is also a redirective blood flow to our muscles and limbs. And so as a result, we become more alert and we're like, ready to take action. But this does not serve us. When we want a child to explore foods and work on chewing and swallowing, we don't want them in fight or flight because our nervous system is basically ramped up in a way that makes us not ready to receive the therapy in front of us to explore new foods, to explore new senses and smell, you know, senses I. By that, I mean how things smell, how things taste, how things feel, et cetera, et cetera, et cetera, right? So ultimately, what we want is that child to be in rest or digest. Okay, and so what is. What is rest or digest? Well, let's say there's been a threat, right? That thread has. The threat has now passed. So our body kind of goes, ah, right. Okay, big sigh, calm down. We shift into this rest and digest mode. Our body is in a state that is like a relaxed state, right? We are now prioritizing relaxation, healing. You know, internally we are very calm, okay? And so the physiological changes that we see here through the parasympathetic nervous system is like, think of it like that break. We're like hit and pump in the brakes. Pump the brakes, stop, take a break. You know, going back to that car analogy, we're calming the bot, or metaphor, I should say, we're calming the body down. Okay? Our heart rate slows, right? When you, when you hear me talking like this versus talking like this with the blood, blood flowing and the increased heart rate and blood pressure, like you're, you may even have a physiological response to that. Like people respond to what's in their environment. So something is exciting and it's pumping you up, right? You're going to have a different response than if I start to talk like, like this. And the breathing slows and the heart rate slows and now the blood flow is not being redirected to the muscles and like limbs, right? It's now being directed to our internal organs. All of this enhances digestion and nutrient absorption. And it's really, really good because it's a stick state of relaxation that not only allows our body to recover and repair itself, but it also, in a feeding environment where maybe there's some other anxieties or feelings around food in front of us. If we're in a state of rest or digest, we may be able to handle those new foods that someone's putting in front of us or handle those oral. Handle those oral motor tasks that are being asked of us, handle that heavier load of activity that we're being asked to engage in. If we're in fight or flight, we can't handle that because we are so far gone at that point. We're so far beyond the ability to do something hard, do hard things, that that's where we start to lose kids. They shut down, right? They're not ready to receive therapy. So it's really, really important that we figure out how to get a child into rest and digest, help them calm their nervous system down. Because we know they're going to have a reaction to certain things. But is that reaction going to be an overreaction? Are they going to be underre. They going to be not overtly reacting? Are they going to be calm. Are they going to be hyper? Like, what? Are they going to be really angry that we've put certain food in front of them? Like, we don't know until that happens. But I can guarantee you that if you can figure out how to get a child into a state of rest and digest, we are going to be more successful with getting them to try new things, expand their diet, work on their chew pattern, work on breaking up food down, you know, into that bolus so that it's ready to be swallowed, and so on and so forth. Right. And so I want you to remember that, that like a short term activation of fight or flight that's critical for survival. It is a survival mechanism. We need fight or flight, but we don't want to be living there 24 7. And unfortunately, so many of the patients that we work with, the children that we work with, are in a constant state of fight or flight as if they're running from a tiger at all times, as if they're hitting that gas pedal at all times. Like, think Energizer Bunny at all times. Okay. And this can actually create like a, this can create chronic stress, which is really harmful to our health. So I would advise, you know, so you're going, okay, great. Well, how do we help a child get out of this fight or flight? Honestly, I think what we talk about on here all the time is a great approach. One, we're going to want a baseline. So we definitely want that feeding evaluation or the myofunctional therapy evaluation to start. We need a baseline whether they're starting therapy with us or not right now. We can then tell if the child is ready to proceed, if they do qualify or need therapy, or we will know if they need to be referred to another provider. Um, some of those other providers may be cranial sacral therapists, craniofascial therapists, you know, cft, cst, osteo, osteopathy, Cairo, pt, ot. Right. There's a number of different avenues and it's going to depend on, one, the child's needs, what are we sending them for and why are we sending them. And two, where are you located? Because sometimes the different professionals in your area that are trained in what your child needs, it could be any of those providers I just mentioned. So it's not always like, oh, just go see a craniofacial therapist or cranio, you know, sacral facial therapist or a Cairo or PT or whatever. It's not always obvious which provider we want to see. So that's where it's best to connect with somebody who is working with, from a team, approach some of these providers and then can refer you to the most appropriate place to help your child, because we ultimately want to help their body find that calm state and then learn how to work with them from that state. Okay, So I think that's a really important thing to mention because when it comes to feeding, right, beyond that physiological, you know, sympathetic, you know, versus parasympathetic nervous system state, that fight or flight versus rest and digest, you know, state. What can we do? Well, there, there are different approaches, right? So if you start with an evaluation and let's say there's a tongue tie present, then we, we may prep the child for a procedure and they may be in, you know, it may be recommended that they have a tongue tie release, which can really help because some people also, especially adults, will explain to you that they're in a constant state of, like, despair, like a constant state of, like, anxiety, a constant state of stress because they can't breathe well, because their tongue ties affecting them. So there could be a number of things going on. And so oftentimes, if a tongue tie release is recommended and you're working with a team that works together and collaborates, they're also going to have a plan in place for you where they're going to probably want you to see a couple different providers in prepping the child or yourself, if you're an adult, for a tongue tie release. Right? And that's not the point of the podcast today, right? But anybody who rushes in or anybody who says it needs to be done now, or anybody who says, let's just do a little snip, run the other direction, okay? Now the other thing too, that's really important is you cannot separate the sensory and the motor systems, even though they are taught that way. They're taught in silos or sometimes treated in silos, Sensory and motor go hand in hand. So with that, we need to be addressing both. Okay? And so, like oral motor exercises will likely be necessary to help improve tongue mobility and strengthen oral muscles and enhance chewing and swallowing abilities. And so you, you know, when you gain better control over your oral cavity, assuming you don't have tissue tethering your tongue down or keeping it flowing forward or, you know, leading to some certain positioning or structural, you know, positioning that you maybe you can't control right now, that's going to help the child's nervous system stay a bit calmer, which also will allow them to open up to more sensory experiences around Food. All right. You see how this is kind of working. And then I have big rules around this, right? So obviously, you can do gradual, like, introduction with foods, and there's different approaches. And some people will say, oh, food chain. Or, oh, use kind of like a, you know, approach where you play with the food and whatever. Look, I think engaging with food is important. I don't think that we need to, like, play with our food for long. If. If the child's really young and you want to play with the food a little bit, fine. But at a certain point, let's do functional activities that bring the food back to the purpose of it, which is eating the food, right? So we're not forcing it, but maybe they're going to the store and they're picking the food out with you, and they're putting the food in the grocery cart. Maybe, you know, they're picking something up and smelling it, and you're going, I wonder which one smells better. Do you think we should get this one or this one? Let's smell them. Yeah, which one do you think? And then they smell it. Okay. They just brought it close to their face with no expectation of eating it. But do you see how they're interacting with the food in a functional way? They're not just like. We're not just putting it on a table and dipping something in it and then building a structure out of it and then never eating it. I'm just saying I don't think there's anything wrong with. Again, maybe playing with it a little bit. But we've had kids come to our practice who have been playing with food for literally a year in therapy, and they've made absolutely no progress bringing that food to their mouth. What are we doing? Like, that's not functional. So that's where, like, the introduction, right there needs to be. The introduction of foods need to have some kind of a strategy behind it. And we are driving the ship here with the strategy. The child is obviously going to respond the way they respond, and we are going to respond to that, Right? We're never going to pressure, we're never going to force, we're never going to coerce, Right? We're going to keep it a very positive experience at all times. However, we can be very strategic with how we bring the food into their environment. Right? So maybe they help us create, cook, or maybe they make a smoothie with us, Right? They see everything that goes in. I am very much so. Not about, like, hiding a lot of things. Like, if we're talking a couple little like drops of some kind of a supplement and you're hiding that fine. Medication. Okay, fine. But if we're talking, you know, if your child really won't take that stuff and they really need it, fine. But if we're talking actual foods, like just hiding foods within other things where the kid is not even aware they're eating them is not going to actually help them. Like, I get that the point of trying to get nutrition into a child's body, but if we actually want the sensory system to develop and to start to welcome in and accept more foods, the child has to be aware that they're eating said foods. Okay. Um, so just wanted to put that out there. But grocery shopping and, you know, being playful with how you pick the produce is great. You know, grocery shopping and then bringing that home and having the child in the kitchen while you cook, maybe they're just sitting on the other side of the counter. Then having your child help you chop the veggies or prep them stuff, or having the child, you know, put stuff into the dish that you're making or having them stir it. These are all really positive experiences because one, it teaches them how to cook something that I really hate doing, but my kids enjoy it. And two, it involves their sensory system in a very rest and digest way where they're not going to have a big response. And if they are having a big response and your child's not in feeding therapy yet, please call an SLP or OT to do a pediatric feeding assessment, sensory or oral motor feeding assessment. Because we don't. We don't want children gagging or vomiting or having these really negative experiences around foods. Foods should be a positive, pleasant experience because we need it to nourish our bodies. Right. There's a actual biological need, a physiological need. Right. So just wanted to throw that out there. And I want you just to remember that every child is different. Okay? So hopefully this is helpful. I wanted to just dive a little bit into the topic of the sensory system and, you know, like, food aversions and tethered oral tissues. Because we do get these kids all the time where it's like, my kid was only eating 20 foods. My kid used to eat foods, and now they only eat 10. You know, my kid only eats certain types of foods. Well, yeah, we tend to see similar profiles where children are eating, like, colors that are closer to beige, white, yellow, brown foods. Right. Not a ton of proteins. Maybe they're more heavy on the carb and dairy side of things versus, like, you know, veggie, fruit, other Protein types of foods, they tend to eat things that are highly processed that easily mash, you know, mash down. Why? Because if we can easily mash the foods, guess what happens? We don't have to chew much, we don't have to work very hard if our tongue's not able to move around our mouth. What are we going to opt for? We're going to opt for the foods that are easier to break down that we feel safer eating, even if they may not be of the most nutritional value. That's just what it's a learned response. We've learned these foods are safe, okay? And a child is always going to pick something that is safe, safe over something that feels scary, that puts right. If they're going to choose something that keeps them in rest and digest over something that puts them in fight or flight, okay? And then people will come to me and say things like, but my child, like, is really picky and only eats like 15 foods. But like, I think they're fine because like they chew steak or they eat hard carrots. Like, why do they do that? I hear this all the time. Sometimes if the child really likes the taste of something or they like the experience of eating it, they may work extra, extra hard to eat that food and try and break it down because they enjoy it. And so they're highly motivated. Okay? But when they're not highly motivated, in many other instances, let's say the grilled chicken and other harder foods to eat, that's where they're like, nope, not happening. Like, that sends me into fight or flight, right? But this keeps me in rest and digest, right? So, and I know I've said it on the podcast before, but there is a difference between grilled chicken and like chicken nuggets, right? Chicken nuggets are basically pre chewed food. It's been a long time since I've said that, but it needs to be said. Again, sorry for that image, but it's, it's food that's already broken down and like form basically then formed back into a little nugget, right? And then cooked, like spreading on the outside and cooked whether it's gluten free or not, whether it's organic or not. It's the same across the board in terms of the texture, right? And the consistency. And that's why kids like it. The texture and consistency is consistent and it's easy to break down, especially for those who have an issue with chewing. And so I know I've done this before, but we get this question all the time. All, all all the time. So I will spend just a moment explaining chewing patterns, right? Because I think that it's important to understand that chewing is what preps food to swallow, right? And so basically, bite and crush food. You take a bite, your teeth come together, breaks the food down into smaller pieces. The incisors, our front teeth, right, help with biting the food off. The molars and premolars help to crush and grind the food. While then the food moves across our tongue, mixes with saliva. The salivary glands release saliva as you chew. That saliva has an enzyme, like, you know, amylase, for example, that starts to break down foods like carbohydrates as an example. And then that moistened food forms a soft bolus, okay? That ball of chewed up food that's ready to be swallowed. And it should be on the center of your tongue. Your tongue then pushes the bolus against the roof of your mouth and the back of your teeth. And it helps kind of mix, you know, mix the food with even further saliva as it pushes it back and gets it ready to be swallowed. Okay? And so your saliva kind of saliva, your saliva kind of acts as like a lubricant, if you will, and kind of, you know, in cases the bolus makes it easier to swallow and there are enzymes in saliva that continue to break the food down. Why is this important? Well, because as this whole process is happening, right, and you're grinding and crushing stuff, you're, you know, with your molars and you're moving food across your tongue to your other molars and you're getting that bolus ready. And sometimes, you know, I've kind of discussed this in a sense of like, okay, we create a bolus. We chew, swallow, create a bolus. We start over. We chew and swallow, right? Food goes in, chew, swallow, Bolus is created. We swallow it back. Some people will swallow back some food before the rest of the food is ready to be swallowed. So then we continue to grind and crush, prep the rest of the bolus. You know, chew it up. It's in a bolus, it's ready to swallow, swallow it back, okay? We don't swallow it back until. Or we shouldn't swallow it back, I should say, until that bolus is well chewed, okay? And then the tongue pushes it backwards towards the throat. Our swallowing reflex is triggered. It moves the bolus into our esophagus, right? And eventually into the stomach and so on and so forth. What happens when we don't chew it well? What happens when we can't chew it well? What happens when we Have a hard time lateralizing our tongue across the oral cavity to chew our food well, we mash it or we munch it. So we either mash it between our tongue and our palate or we munch it between the back molars. And our jaw goes in an up and down motion, right? We're not. We don't have that circular rotary motion that we should have with the jaw. And we don't have what I described before with the food going across the tongue and mixing well with saliva to break down. You know, the enzymes break the foods down. It gets it ready to be swallowed. It basically, you know, that saliva acts as like a lubrication around the food, around the bolus, you know, and in the bolus to basically help make swallowing easier. When this is not happening, we see kids actually swallowing pieces of food. So they might be chewing that carrot, they may be chewing that steak or even bread products or other items. But if they're not prepping it properly, they're swallowing whole chunks. That's going to impact digestion. So then we have to ask, is the kid constipated? Does the kid have tummy aches? Does the kid have a distended stomach? Does the child have like, issues with bowel movements beyond like, that are maybe different than constipation. Like, what is going on? Because when we start to look at these things that starts to go back. We start to look back into the window, into all this, which is what is happening in the mouth. And that is why my recommendation, when there are feeding aversions and there are maybe tethered oral tissues that play like tongue ties, lip ties, there's an orofacial myofunctional disorder at play. The mouth is open, we're mouth breathing, the tongue is low and forward when it's not up on the palate where it should be, and so on and so forth. That's why I recommend we start with a feeding and or MYO evaluation because that is going to give us insights into all of this and it's going to help put us on the right path or trajectory towards helping the child. And then those food aversions that we have can be addressed or those food aversions that may be starting to occur, further ones can be prevented. Right? We can start to work on bringing food back into the diet or slow the elimination of further foods. So highly recommend, highly, highly, highly recommend a feeding evaluation with a pediatric SLP or OT who is also trained in myo. And so a great place to a resource where you can search for these individuals is pediatricfeedingtherapist.com you might have to put the www in the front of that, but that is a resource. We've had over 2000 SLPs and OTs. Actually I think close to 2200 at this point. We've got more going through the course right now that have gone through Feed the Peds and they've learned about this and many of them have also gone on to take further, you know, education in the MYO space, which we are working on a MYO directory as well, specific to just Myo for those who are maybe not in the feeding realm but who are doing myo, have taken our MYO course, who are getting certified through the Certified myofunctional Therapist CMT that we offer as well. That's where you want to look. Okay? And if you know, I always invite people. If you can't find somebody on pediatricfeedingtherapist.com reach out to me at Hallie Balkan on Instagram because I can ask some colleagues and see if there's anybody in your area. If you're having a hard time finding somebody, I hope this is helpful. If you have more questions on tetheral tissues and food aversions or the nervous system and the likes, let me know. But hopefully this was helpful, enlightening and all the things. I'll talk to you guys soon. 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@hallie balkan.com or pop over to hollybulcan on Instagram to get all the latest updates.