Episode 36: STEP Into Infant Feeding: Paci’s And Bottles And Pacing, Oh My! With Joan Comrie

Hi and welcome to episode 36 of the Untethered Podcast. Today we have Joan Comrie joining us. Joan Dietrich Comrie received her BS and Ms. At the University of Wisconsin, Madison. She's the owner of Pediatric Feeding and Swallowing located in St. Petersburg, Florida. After 10 years of working in the neonatal intensive care nursery, she started a large pediatric feeding and swallowing practice in Raleigh, North Carolina which she had for 20 years until she moved to St. Petersburg in 2015. She has treated over 5,000 patients focusing on infant feeding and swallowing. Her clinical expertise has enabled her to provide real examples used in her presentations at national and international conferences and workshops. She has guest lectured for UNC medical residents and graduate level speech pathologists during pediatric grand rounds and physician meetings. She provides hands on learning opportunities for feeding therapists and lactation consultants. Part of her mission is education for parents and professionals. She started Pediatric Feeding and Swallowing Academy in which she is a live course for lactation consultants and soon her course for feeding therapists will be available. Joan has also published an article in Seminars in Speech and Language on infant feeding. She has also responded to parent questions in the Health section of News and Observer, Raleigh's newspaper and in parent magazines. Her success is due in part to her step Program System Systematic Therapeutic Eating Program in which she breaks down the sensory and motor skills required for successful feeding and swallowing into understandable steps. When caregivers understand the process and how skills build on each other, they are more likely to follow the program. This compliance enables progression as quickly and as smoothly as possible. 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 orofacial myologist, Feeding Specialist and Mentor.

This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses.

Let's get started. I want to thank you Joan for joining us on the podcast today. I'm really excited to have you here.

You're welcome. I'm really glad to be here.

Well, let's just jump right on in and start talking about optimal timing of release. I would love for you to share what that means to you and how you use that in your practice.

I think that is something that's so important and sometimes overlooked. And I think in part, maybe a lot of the Facebook parent on parent conversations. Is this a tongue tied? Should I get it released? I think it's super important to get with your preferred providers and talk to them about the optimal timing. And some of the things that need to be considered is you definitely need to understand the baby's oral and sensory motor skill. Do they have active patterns or are they more restricted? And even if a baby has passive. So I like to make a delineation between passive and active patterns. And so passive range of motion to me would be, can I lift baby's tongue up into the roof of their mouth? If I can do that, then they may or may not need a release. But it's more likely that they just are not, for whatever reason, using those patterns. And so if you have a baby whose tongue is sitting flat on the bottom of their mouth and you do a release, it's likely that that baby is not going to start activating their tongue. Even though they have that range of motion that would enable them to do that. They maybe don't know how to do it. Maybe they've never done it. Those neuromotor patterns are not integrated into their system. I think it's really important to make that delineation. And I think sometimes just because the baby doesn't have that passive range of motion, they'll get the release. And I think that's why, in part, parents aren't super happy because breastfeeding is still a problem or whatever kind of feeding that they're doing. And it's really interesting to me. I just moved here to Florida four years ago. In the first two years I was here, I was still going back to North Carolina with my private practice, running it remotely, and then realized that was not working very well. So, you know, I sold that practice. But what I. I was in North Carolina for, I'm guessing like 28 years, working in the hospital, in the NICU there, and then started a private practice after about 10 years of being in that NICU, or eight years, I think it was. And so everyone knew me, I knew all the resources, they all knew me. And it was awesome because I would see almost all the babies before they actually got the release. And that way I could teach mom and dad or whoever the caregiver is, how to get in a baby's mouth, how to be comfortable, what to look for, how to make some teaching them some of the Stretches that the ent or the dentist would be teaching the parents what to do. And so they're feeling comfortable and competent about getting in the mouth. So it's not like they got the release. And then they're like, oh my God, the baby's screaming. Like, do I have to stick my fingers in there and make them more upset? And so baby was more comfortable with having someone kind of invading their territory. And we could work through some of the motor issues. And I feel like, so here in Florida, not as well known, people are just starting to get to know me. I see most of the babies here after they've had the release and then they considered a fail because the baby isn't feeding, still is not feeding well. And so then they'll find me or they'll a lactation consultant or someone will refer them to me. And I feel like they would have done so much better if people would have looked at that facial and head symmetry, looked at where is that baby's tongue rest position? What does their mouth look like at rest? Is their mouth wide open? What is their muscle tone like? What is their breathing like? Are they open mouth breathers? Are they nasal breathers? Does that tongue float to the palate when the mouth is closed, or does it still hang low in the mouth? Because we know that tongue is that natural palatal expander. And so it's so important for airway. I mean, you know, that you have all the airway people. It's awesome. And then I think it's really important to look at what happens when baby's crying, because if they don't have really active function, if they can passively lift that tongue up, or even if they're screaming their heads off and that tongue doesn't even elevate, that gives you a lot of information about what their range of motion is like and what maybe could be supportive of that baby to ensure that when they do get that release, all the systems are as intact as they can be, baby's as functional as they can be, and so they get that release and things just seem to fall in place a lot better. Babies still may need feeding therapy or intervention by a speech pathologist or someone who has that expertise. But at least that baby is ready because their muscles are balanced, their movement patterns are organized, their nervous system is more resilient, and they're able to tolerate the procedure. I've seen babies here in Florida way more than I ever see in North Carolina that just lose their mind. And they are, after the procedure, screaming for weeks. And I Didn't see that up in North Carolina. And I guess I didn't until I came here, didn't put together that babies were better prepared for that procedure than they are down here. If they don't get any kind of bodywork, whether it is a speech pathologist or chiropractor or craniosacral therapist, whomever is actually moving that body system and making sure that that baby is ready and that they have a competent airway. Because as you know, there's some babies that really do not need to have that tongue released or they're going to get into airway trouble. And I think a lot of times people are not aware of that and as much as maybe they should be. So I think those are important.

I think that's a really interesting distinction between North Carolina and Florida to see, you know, when you kind of went like, wait a second, what is going on here? And you kind of, you realize when something is so second nature to you because that's just what you do. You do that optimal. That, you know, it's optimal timing. We do that pre op work and all of a sudden these babies are not necessarily getting it, or maybe they're just coming for, you know, to see you once and they're not actually getting enough care pre op. And then, you know, that's when I first got into working with babies. That's what I was getting. I was getting a lot of these babies who were not getting any pre op work, they were getting released. And then now they're three months, four months old and breastfeeding has failed or trying to, you know, mom's trying to go back to work, or they're five, six months old, they're trying to introduce solids and that's not going well. And there just seemed to be this like 4 to 6 month old age that where I initially I was getting a lot of babies in that range and I was going, something's off here, too late, something is off here. And you know, and it just. Can we get them back on track? Sure. But it's going to take a heck of a lot longer and a lot more work on mom and dad and, you know, all the caregivers involved and the therapists involved and the team as a whole. It's just, it's a much more stressful process and a lengthy one at that. And so it's really amazing to see what happens when you prep the baby properly.

And the parents.

Yeah, right. And the parents. And that's. And right. So the parents, you know, when I say Prep the baby too. I think in my brain I just go, really? That's the parents, right? You have to kind of encourage them like, hey, this is what we need to do beforehand. This is what's going to happen, you know, during the procedure and immediately following. And you might see this little roller coaster of baby, you know, and the so many days following the procedure. And then with all the work we've done and you know, we should see X, Y and Z. And if you don't, then they might need, you know, A, B and C. And I just think that having the education component in there for the parents and doing that pre op work is, I mean I've seen such a huge difference. But then also going and talking to those release providers and being, you know, and making sure that they're aware of this as well, because I just think people aren't aware and they just hear, oh, tongue tie releases. It helps the baby. Let's, yeah, let's help the babies. And so I don't think anybody in my area is doing it to harm the child, but I think there is a lot of harm coming out of it because of the lack of information or education surrounding optimal timing of release. Which is why I wanted to jump right into that topic. So thank you for that. And so when do you feel post release like feeding therapy is indicated and I guess even maybe delineating between like babies who have had pre op and babies who haven't had pre op or is it really, do you look at it separately based on those factors or are you just looking at a set of symptoms?

Well, I guess you can look at it separately but together. So if the baby's already been in, let's say in session with me and we've been working on the patterns, then once they get that release, I'm ensuring that the baby is as active as it possibly can be given the range of motion that they were just provided by the release. That the hard part is the babies when the mom comes in and they're like super, super frustrated because they feel like, okay, I've spent all this money because at least here in Florida it tends to be a dentist and medical doesn't cover it. When I was in North Carolina, most of the babies I saw went to the ent who did a phenomenal job and was actually trained by, with Kathy, Jenna Watson. And maybe I said her name backwards, I always forget if it's Jenna Watson. But anyways trained up with her. Like we got her connected, it got them connected and Dr. Karelis and so Both it was a female and a male physician. They were extremely good about care. Whereas down here, it's a dentist and they're paying out of pocket and they're really frustrated. And the last thing they want to do is then go into more therapy. But you know what I'm trying to help people understand one is coming before, but if you're not, then if the baby has that good range of motion, passively, but they're not activating, it is time. Don't wait. Don't wait weeks. If the baby's not doing it immediately, it's not going to happen. They just don't have that muscle pattern. They don't know what to do. And we forget that baby starts swallowing, you know, gestationally at about 16 weeks, I think is about the time. So if they have the restriction of that tongue, they have been compensating. And we know compensatory patterns by babies are not typical patterns. They're compensating for something that's not working right. And so they could very well be compensating from, you know, 16 weeks gestation. And then if we end up getting them by, say, six to eight or worse, 12 weeks, they have been using patterns that have not been very effective for a long time. So the importance of feeding therapy is so that we can identify what those patterns are and then, you know, help eliminate those patterns. Because if those aren't eliminated, then they're not going to use a new pattern. And, you know, we are not motivated to change our ways unless something's not working for us. Same thing with babies, you know, if mom has a good milk supply, or maybe not, or maybe they're using the SNS or whatever they're using to help facilitate the feeding patterns. But we're not changing the baby's motor patterns. And the baby's still getting fed. They don't realize that they need to make a change. For me, like, and I might be, like, jumping around, but that made me think about the mom that allows the baby to get this little tiny latch. And she's like, it's okay. It doesn't really hurt that much. I'm like, okay, but your baby is a few weeks old when they get to be, you know, 12 weeks old. And they're really strong and they're not using their tongue, they're using their jaw. It's not going to be very helpful. And the baby's not going to change because they don't know they should change. Right? They don't have that motor pattern. And so I try to tell moms what you're allowing the baby to do is your way of saying, this is okay. And if it's not okay to tuck your lips in. Because we know, like when I do presentations or even when I'm talking to moms, I'm like, pull your lips in. And everybody pulls their lips in. And you're like, where'd your tongue go? Retracts. That's the exact opposite pattern that you want for breastfeeding. You want that tongue to come forward. And so if the baby, instead of having these nice flanged lips, is tucking those lips under, you're telling them it's okay. And maybe in the first six weeks it's gonna work because you've got your, you know, mom's tanking up for baby and really compensating so baby doesn't have to do very active patterns. And then all sudden growth changes, neurologic and central nervous system maturation, and things just start to fall apart. And they wonder why. Well, it's because the baby was never set with a good set of patterns.

Yeah. And I think that, you know, as far as post release goes, the other issue that is, or I guess, statement that is said by some professionals that is not helpful is about weight gain. Right. You'll get a lot of pediatricians say, oh, well, they're gaining weight, so they're fine, you know. And again, this is not to speak negatively about our pediatricians. They are generalists. They're not usually specialists, and they don't know it's an issue unless you bring it up. But a parent may also not know it's an issue unless somebody has brought that to their attention. So here we are in this cycle of nobody really knows what to talk about. They just know something's not working and no one can quite figure out what to do about it. And so I think that's when feeding therapy. Also, if something seems off, regardless of whether or not baby's gaining weight, as you've mentioned here, I think that's a really, really good that we need to really highlight out there that people know weight gain is not the end all, be all.

And it doesn't rule out a feeding disorder either.

Right, Right. I have a very picky eater who had her tongue tied, release it too, who was always in the first percentile. And what my pediatrician would say was, well, she's on her own growth curve and she's still gaining, so she's fine. And even within utero, they thought about inducing me early because they noticed that her brain was taking all the nutrients and her stomach was not getting them. And they said, you know, if this continues, we might have to induce you early. And then she ended up being fine. But she's just always been this little tiny. And I always joke, I'm like, I wish I had that issue and had this tiny little petite waist. But in reality she was that child who had a very shallow latch. I took her to the lactation consultant and it's like you take your part of the shop and everything works fine while you're there.

They said, oh, she's great.

I don't know what the problem is. Like, go home and just, you know, try this new hold I showed you. And obviously it didn't work. And our 45 minute feedings continued around the clock for 13 months. So and it was never okay. But in my mind, even as a new mom and someone who was doing feeding therapy at the time, I was not working with infants. I was doing like the two plus or the 12 month plus crowd. And most of them were moving away from breastfeeding and really, you know, on open cup straw, cup solids, spoons and forks. And, you know, so for me, I didn't even know as that feeding therapist that this was not normal and it shouldn't hurt and you shouldn't feel it. Until I then had my second one. I did learn, but then I had my second one who was released at day five and immediately, like you said, it should start working right away. And she immediately latched. I was like, I don't even feel her, I can't feel her feeding. Like, this is bizarre. And we had a great feeding experience after that. So, you know, had we not, she would have been seeing a feeding specialist other than myself because as a new mom, I was like in la la land. But yeah, you can't be a mom.

And a therapist at the same time. You know. An interesting story. My first son was preemie and I had worked in NICUs for 10 years and he went to my NICU and I'm like, dude, you're supposed to come home, you're not supposed to be here. But anyways, I was very competent feeding bottle feeding babies because I've done it for like about 10 years when he was born. So if he took a bottle, he was a professional bottle drinker. Like, never choked. Every time I nursed him, he coughed and choked and split and it was just so hard. And he's old enough now that, you know, it wasn't the day when we had iPhones, which I You know, and I was a mom, but I was also a feeding therapist, and I should know how to feed this baby. And if I could have videotaped this awesome pacing technique that I did with him, like, he would have one or two socks. I would give him a non nutrient. I'd pull him off. I don't know if you can see, pull him off, give him a non nutritive sock, put him back on. He'd do one or two socks. We did that through the whole feeding. I don't remember how many months, because I was so, like, devastated that I went home without a baby, you know, but it is the technique that I use with some moms now. And it just was so rhythmic and coordinated and organized, and it was just like such a beautiful thing. But I know, like, it's. We all have babies as soon as.

You have your own child and you're like, new mom, no sleep, and hormones are glaring. You're kind of like, what do I do for a living? Is this normal? I can't remember.

And I guess there's always a silver lining, right? So with him having some early breastfeeding issues in the nicu, of course, because he was intubated and blah, blah, blah, he had all those interventions that are not very supportive of oral function. Even though I will, I do admit, and I even told the neonatologist, when he was intubated and no one was watching me, I was in there working on his oral function. And it's really interesting because when I went back to work, the neonatologist is like, joan, I cannot believe that he was such a good bottle feeder and he could breastfeed because when he was born, he didn't have a sock. And I'm like, wow, when you turned.

Your head the other way, I might.

Have been doing, you weren't watching me. And then, of course, I'm praying, I'm like, please do not extra, you know, extubate this baby or, you know, cause. Cause him to desat or something. I was like, but I really honestly think that that early intervention that I did made a huge difference in his ability to feed.

It's very.

Not that I'm advocating that work in the NICU go when a baby's intubated to work in their mouth. But for me, that worked, and I think that was very supportive of his oral function.

Yeah, well. And I think that just speaks to the whole early intervention. Right. The sooner we get in there, the earlier we can change those patterns and get rid of the compensatory patterns that they might be using and correct them. And obviously the earlier it is, the easier it is to do that because, you know, the more time that they pass, just the more solidified those, you know, atypical patterns become. So. Which you've spoken of a bit too. So I think that's also a really good.

And I think when I've had other professionals or physicians or whomever say, well, they don't really know when I should refer them to you, I'm like, as soon as you think there's an issue, because the best case scenario would for me to say, do X, Y and Z. Baby looks awesome. This is going to be just a short little tweaking and you're good, you know, and then the other, I guess, best case scenario is you got in early because we know, as you said earlier, when I get a baby in their three plus months to work on breastfeeding issues, I'm like, this is going to be so challenging because their patterns are so set by three months. Really hard to make some changes.

And you can do it, but it takes a long time. And I also find that those cases that come to me that are past that, like, let's say three month, four month mark, then typically also have issues down the line. So even if we correct what's going on right now.

Right.

Tend to still, then they're coming back to me when we switch to solids, and then they're coming back to me when they switch to an open cup, and then they're coming back to me, you know, and so. And we can work on some of these things along the way in anticipation that there may be some later challenges and to try and, you know, avoid later feeding difficulties. But it just seems to be the case that those are those calls that I get, you know, I get those repeat calls. Hey, we're back. Come on in.

I'd love to see you, but I'm sorry that we have to meet up.

Exactly. I love you and your child, but I'm sorry you had to call me again.

Right, yeah. So.

So let's talk more about the sensory and motor, you know, relationship with oral function and development. And, you know, it's not just oral development.

Right. So, interestingly, several years years ago, I was asked to speak at the NOMASS conference, the neo. I don't even remember what it stands for. You know what I'm talking about. Yes, I know you're talking about speech pathologists know. And I was asked to speak about the motor part of feeding. And I said, but you can't Separate motor and the sensory. They're so connected. And she's like, well, I want you to do it anyways. Which I wasn't able to do because I always made. I made it more focused on motor, but I also had to hit that sensory, because you can't. And I think that's what a lot of people try to do. They try to say, well, it's a motor function, but if you have a motor function, you're going to have a sensory component somewhere. You know, you just cannot separate it. It's like when I did some consulting to the public schools, they said, well, only teach us about oral stage. We don't want to know anything about pharyngeal because we only stop at the mouth. And I'm like, but you. The swallow doesn't stop at the mouth. You can't stop at the mouth. Kind of the same thing. So if you think about some of the. So if you have a baby that has restricted range of motion, they're not getting their tongue to touch the palate, they're not getting the lateral borders to touch the cheeks. They're not activating movement. So they're not used to having touch in their mouth. And so when you go to latch that baby, and so this is the baby that may or may not have that nice wide gait to get the latch, and then they go like this. Yeah, they pull off. And so that's why we need to think about sensory. And for those babies, I teach moms some desensitizing, some really easy exercises to do in the mouth to have the first experience, not be this breast nipple that's coming into the mouth. It's something that helps them be comfortable so that when it does, then they can activate the motor patterns and get that nipple to that hard, soft palate juncture or close that we really know that is seems to be the placement for, you know, best breastfeeding. And so if you don't address that sensory component and you just look at motor and you just try to get a better open mouth, or you try to get that tongue in neutral, you missed the huge piece about what's going on. Because, you know, feeding incorporates motor learning and motor control. And that integrated sensory information is super important for developing those motor skills. And a thing I tell parents that everybody can think about is, let's say you're going to pick up a glass of water and you overshoot, right? You think that looks like it's a really heavy glass, but it's empty and it's light and you just like, phew. I mean, that's another way that sensory influences how our motor pattern is. And I think one of them, a couple things I think happen when baby doesn't know how to move that tongue and get a good motor pattern, then the compensatory technique is that biting or the compression dominant pattern. So if the tongue doesn't work, the jaw is going to take over for them. And so you've got this super active jaw that you have to help get more graded to enable the tongue to function. And I think for me, like when I'm looking at babies, the two like really big things that stand out to me. Well, a lot of things do. One is a lot of times the babies I see, their head is misshaped and they have preferential head positioning. Even some of them even have gotten it by the time they got to me to the point where they're probably going to need a helmet. But most of them just using some tummy time exercises and just being cognizant of how you're wearing baby or where baby is being positioned. Because all of those ranges of motion allows that tongue to be more active. And it also gives them proprioception and touch on the outside, which then provides some touch on the inside. And if you can get that same sensory piece, then you can start activating your motor patterns a lot better. And so I see a lot of babies with tongue retraction and that can be because they're restricted and as they move, that's the only way that their tongue can move. But if you continue to see it and they have good range of motion, or if they never really had a tongue tie and they have good passive range of motion is what I mean by range of motion. Then we need to do some techniques to get that tongue to come a little bit more forward. A lot of times integrate sensory like desensitization type exercises and then actively getting in and changing that humping tongue to the cupping and that central tongue grooving. And when I can get a baby to get that central tongue grooving more consistently, that jaw stops being so active. And I do a lot of jaw support even during breastfeeding. A lot of the babies that I see, maybe you see as well, are little extensor dominant. So they like. And it's probably airway related as well as maybe motor tone related. They love to keep that head in extension. So I do a lot of work to help get more of a Rhona Alexander. I have taken a ton of her stuff when I was in my early feeding stages. And she talked about capital flexion, which is kind of the. It's not a lot of flexion, but it's kind of like what I have right now. So you're eating dinner and your head is just kind of down, but your neck is elongated. So we work a lot on those type of positionings because positioning will also affect your sensory, which also affects your motor. And then, you know, I can. I have a little baby. I love it.

I love her. I love the baby.

And so I know Michelle does a lot of tummy time stuff. I do tummy time as well. And I think we probably have similar focus. But I talk about planks. So I have baby's hips on mom or dad's one leg and then their elbows. Let me see if I can make it work. She's not flexible, but I get a 90 degree angle with those elbows in a plank position because I have so much head extension. So I've got turtles. I got babies that do tummy time in the turtle and then their legs are hiked up and they're like flying like Superman. And for the babies that I see, that aggravates their reflux. That aggravates, you know, their muscle tone. It just keeps them really disorganized. So if I can get that, and I tell parents, you have to feel that elbow bone in your leg. So if you don't actually feel the weight of that shoulder girdle through the elbows onto your legs, then you don't have the right position. But if you feel that, then I feel like that baby lifts through the shoulder girdle and I'm going to move the baby instead of hyperextending. So, you know, body's baby's body stays the same, but they can lift like this instead of lifting like this.

Interesting. You're saying this, and I'm like thinking back to my first child who hated tummy time and who I could put her on me and I could put her across my lap, I could put her on my chest, but on the floor. It was like finally, maybe around three or four months, we propped her up on like a boppy pillow or something. And then she tolerated it on her on the floor and not actually on a human. And we worked through it. But yeah, I mean, that I'm thinking of. I'm like, I'm sure I've got videos and pictures I can go back and look at because I'm sure that's probably how she was. And that makes a lot of sense that if we had you Know, I had this idea of kind of doing the planking with her. I wonder how that would have been different. Now I'm going to go try that with some of my patients.

With yoga being so popular, everyone knows what a plank is and so we talk about. And of course, the baby's hips are on the mom's legs or dad's legs, so they're not having to hold a real plank. But their upper body is more in that plank position so that you're getting that lift through the shoulder girdle, because obviously we know we're all connected. So shoulder is going to support neck, which is going to support jaw. And if you don't have good jaw stability, you're not going to get any tongue movements that are as effective as.

They need to be. I love that you brought up posture because, you know, body positioning and feeding and tummy time, especially with the whole container baby thing going on with every. You know, babies are just kind of left in containers because everybody's so busy and we want to keep our children safe. We think we're keeping them safe by putting them in these things, but we're actually doing more harm that way. It's just, you know, a very interesting society we live in and we're having to do a lot of cleanup.

Or even the babies with reflux, they're told to be upright, you know, 90 degree angle or 45 degree angle. They don't have the core to support that in those containers. So they're like this and can't breathe, you know.

So, yeah, it's like, which one are we gonna promote at the moment?

Yeah, I'll tell you another little tip that I do. I'm gonna pretend that this is a towel. And so what I have, and I always say, dad, this is for you because they feel helpless, right? Mom's breastfeeding and they're just kind of, you know, holding. So I have dad take a non stretchy towel. This is a paper towel, but that's not what you want.

I'll pretend it's a towel and you.

Want to roll it as tight as you can and you want to make it about the size of a quarter, but it depends on the size of the baby. And so that when you go like this, it does not smash. So I'm not taking the time to do that. Right. And so then what you do. And of course this is not crash tested, so you don't ever want to do it in a car seat that you're gonna put in a car. But if they're just sitting at home, then you put it behind this part of their neck up to the top of their diaper, right. And then put them in their car seat like that or whatever. They're sitting in their little boppy thing so that now instead of sitting like this, they've got that thoracic spine support and they can actually sit more comfortably. And of course, you always have to watch a baby, you know, even if you're just putting them in a seat, but that way you at least give them a little bit of the core that they don't really have yet and they're not like stuck in a place where they can't even breathe and then they're spitting up more.

Yeah, that's interesting. Yeah, that is interesting. I haven't seen that support before. I know we do a lot of roll up towels and different seating situations for positioning for solids or even to support mom when breastfeeding and obviously some supporting positioning for mom, but that is an interesting one. Thank you for showing us that. And for those of you listening to the podcast, we will also put this up on YouTube. And so the video will be available for anybody who wants to pop in and take a peek at what Joan is sharing with us. Because I'm learning. These are great. Thank you. But yeah, it really does matter. Positioning is a huge thing. Just as important as keeping sensory and motor intertwined because really you can't sense separate the two. It just doesn't work that way. So I love how you also talked about that. And I remember right out of grad school, my first feeding course I ever took was with Lori Overland. And that was one of the things she said in that course that has stuck with me always, that she said, people will teach it as though they're separate systems and as though they operate independent of each other. And she said, you cannot. She's like, they're like this throughout the entire body. You cannot separate the sensory system from the motor system. And I just, for some reason that statement to this day, I just, I find myself saying it to other people. I'm like, well, Laurie Overland taught me that. So I'm glad that you also subscribe to that.

Well, another couple. I have a couple other little things that have always stuck in my head too. Rona Alexander would say, what you get if you want the lips get the hips right. So there's a positioning thing. And then I've always taken courses that were not necessarily speech path, you know, for speech pathologists. Like, I took Mary Masseri's breathing course a long time ago, and I was the only speech pathologist in the whole room. And they all kind of looked at me like, what planet are you from? Why? And I'm like, well, because I work on feeding and swallowing, and if you can't breathe, you can't eat. And her thing is, if you can't breathe, you can't function. And truly, you know, everything that we do, all of us, no matter who's listening, you know, speech pathologists, OTs, lactation consultants, nutritionists, physicians of any sort, you know, if you're not breathing, nothing else is gonna work for you. So we, you know, that's why the positioning is so important, why sensory so important, motor so important. We are protecting that airway, and you.

Really have to optimize the airway. It's not always just like about, Well, I don't want to say it's the wrong way. It's not just, can we breathe? But are we, you know, like we say, optimal timing of release. Are we breathing optimally? You know, I like that word, optimal. Because if a child is mouth breathing and they have enlarged tonsils, and I even seen this in children who just had a ton of reflux and they're all irritated or there's maybe there's inflammation in the back of the throat. There's just. There could be so many variations of symptoms going on. But if they're mouth breathing and they're not nasal breathing and we're trying to breastfeed them and they can't breathe through their nose, well, you know, it's not going to work. You know, And I always say, breathing is life. You can't breathe. Your head. I know it sounds so morbid, but I say that sometimes, and I've said that to families before, because they don't quite grasp how important breathing is. And they go, well, we're not here for that. Like, we'll talk to the ent. We're here for feeding. And you won't breastfeed. Well, he can't feed if he can't breathe. So we can't bypass step one. That is always step one. We have to make sure we can breathe. So I love that you bring that up as well, because that's a big soapbox of mine.

Yeah. And on every evaluation, I teach them the plank, if that's needed, how to keep babies. So hands are at a midline when you're holding them, because a lot of them like to be back here, right. And then closed mouth breathing and, you know, nasal breathing, I guess I should say, with their Lips closed. And I'm like, sometimes they're sneaky. Like one little baby had their lips closed but had the tiniest opening and was breathing that way. And I'm like, you just are. So, like, we both were like, is he breathing through his nose or his mouth? And, you know, we figured it was the mouth, it wasn't the nose. And we thought, sure. So that's just so important.

Yeah, yeah. So now you have a step program, right? Your systematic therapeutic eating program. Can you tell us a little bit about that?

Yeah, it's got several steps. And so I have it for breastfeeding or bottle feeding. So those steps. And then I also have it for learning how to. So the steps are progressing you towards chewing. And so my bias is that spoon feeding, at least for the kids that I see. So I see anybody that's snagging on their typical development or having delays or compensating in ways that are not very functional for them, I feel really strongly that spoon feeding is an advantage. Now. I totally respect the baby led weaning process, but I wish a couple things would happen. I wish we changed the name because I don't think the baby needs to lead the process. I think they need to be in the driver's seat. Like, we're providing the food, we're providing the supports, maybe body supports or whatever it is. But they're telling us like, Ellen Satter, I don't know if you know her, she's a nutritionist out of Madison, Wisconsin. That's where I went to school. And she talks about that division of responsibility. Our responsibility is to provide the good looking, healthy, safe foods. And I think what happens with some of the baby led weaning is that people get really excited and they provide foods that are not appropriate for the baby skill. So if they're starting baby led weaning at six months and they're providing them a stalk of broccoli, I don't think anything good is gonna happen with that. And I wish that because there's so beautiful things about baby lead weaning. But it's interesting as I'm reading that, you know, learning about that, you know, process, which is what, like 10 years old or something like that? Yeah, first came out, it has definitely evolved, which is a good thing because when it very first came out to me, it was a little scary because they showed up, you know, how to Heimlich and blah, blah, blah. And I'm thinking, but you shouldn't get your baby in a position that they're gonna maybe be Choking. And so in feeding therapy, probably because I'm a speech pathologist also, although I don't really do a lot of speech therapy, I almost always do feeding and swallowing. But choice making. Which one do you want? Do you want a spoon? Do you want to feed it to yourself? You know, hand over hand? If the baby needs that support. There's a few things that I think you need for swallowing of more complex food and that is that you need to have. And a lot of this is the myo work. I'm not certified, but I did take Daniel Garleiner's course a zillion years ago.

How cool. I don't know, but that's really cool.

I was trying to surf that because I was like, I wonder if that guy's still alive because I know, I mean, my oldest is 25 and I'm pretty sure I went before he was born because it was out of state, whatever. But it's really important to get that lingual propulsion. So when I see the picky eater kids that come through my office, they all have skill deficits. They just, they can laterally transfer that food, but they can't completely masticate it. And then once the they even get it sort of chop chewed, they don't know how to swallow it appropriately. And I think what that puree does is it takes you from the infant suckle and suck swallow, breathe pattern to getting good, you know, anterior, medial, posterior tongue elevation to get a good swallow. And you don't, I think if you don't get that neutral tongue position and you don't get central tongue grooving so a place for that puree to go, you're really going to have trouble with more solid foods. And so what my system does is break it down in really easy language that parents can understand. This is what I want you to look for because we're not going to transition to the next spot until we see that the baby is starting to do this. So I'm not going to be providing them anything. They have to chew if I'm not seeing, seeing lateral tongue movements.

Yeah.

And so if I don't, if I'm working hard to get lateral tongues and I just can't get it. I look and see what their trunk is doing and I watch them crawl because if they're crawling straight like this and there's no like hip rotation, they're not going to get that tongue. And so I'll pull out some of the things that I've learned from my OT and PT friends and, and just give Them some guidance on how to start getting better trunk rotation and then make the referral if that's necessary. Sometimes they just need a little tweak of some ball work.

Yeah. Like someone needs to show them how to do it the first time. And they might, you know, it kind of clicks.

But not always get that activation because you know, your early feeding experience is the foundation for your speech development and your feeding development and all kinds of other stuff. So if you're, you know, I've had handfuls of babies that have gone through traditional baby led weaning and they come to me somewhere between 18 months and 2 years of age and they are so orally aversive, they won't look at a new food because mom said, you know, he would gag and vomit every time we gave him a new food. And I'm thinking, but why are you giving them that food? Right?

You're like, don't you think that's a sign? Like how?

Especially when they get to the point of vomiting because that gets gross and messy. Like that does not sound much fun.

No.

So then you have to like build the trust and bring them back to feeling comfortable that their mouth is working.

And reset that whole sensory system, you know, the sensory motor component there.

Because now they just see certain foods.

And their brain just goes vomit.

Right, exactly. And then a lot of things that I'll seek because you know, at that age, if they, if they tried breastfeeding and they failed or they didn't even try breastfeeding and they had a tongue tie, it wasn't addressed. All sudden, we're chewing. Child doesn't really know how to chew and they've got, they put a lot of food in their mouth and they use both sides of their chewers, the lateral bite surfaces at the same time because they don't know how to make that lateral transfer. And they have some scatter all over their mouths. I mean those are a lot of the kind of typical things that we all see with kids that have the tongue tie. So you just really need to get build those skills. And so like I said, it goes through the process of moving yourself from a smooth puree. And of course it incorporates helping self feeding, giving child choices, letting them say when they want it, you know, not when they want to eat. Because maybe it's, you know, they, they're sort of within boundaries schedules. Like if the baby says, I don't want to eat, of course you're respecting that, but you want to sort of set up a little structure because that's really Helpful, especially if you move into the toddler, into the toddler ages. But, you know, we're looking at what kind of skills does baby have? And I help really empower parents because you may see this. I mean, you see the child just starts to learn how to chew some easy chewing food and then all sudden they're giving them the entire buffet.

You know, like they eat a baby mum, mum. Or they chew like a little veggie straw. And then the next thing you know, they're giving them, you know, little pieces of steak and chicken. And I'm going, how did it get from this to this? Yeah, some children can handle it, but not the ones that I usually see.

Right.

Truly.

And they can go from having a beautiful pattern on those. And you'll see it in your older kids, right. You give them their junk food or a pretzel or whatever it is, and they have beautiful chewing skills. But then you give them something more complex like broccoli or chicken off the grill, and they just cannot deal with it.

Yeah. And I like how you say chicken off the grill because, you know, a lot of parents go, they eat chicken. I'm like, I'm not talking about pre ch. Chewed chicken nuggets. And I call them pre chewed. And the parents go, that's kind of gross. And I'm like, but if you think about it, it's like somebody already chewed it up and then reformed it for them. That doesn't count.

Definitely is pre chewed.

Yeah. Well, I love your step program. That sounds like it's very helpful for parents, I think too, to understand why you're recommending what you recommend. And it kind of breaks it down into simpler steps in a way that they can see, oh, there's a reason behind my recommendations. And you know, before we go from point A, we can't go point A to point C, we have to do B first. And they need to, you know, really master each step. Because I think a lot of parents just go, I just want. I just want to be able to go to a restaurant and not take a peanut butter jelly sandwich in my purse. Or, you know, like, they have this end goal in mind. Are like, and how quickly can we go from where we are now to, you know, them ordering off the kids menu or even eating something that I order off, you know, the regular menu. So I think that's really great because it helps pace them as well when they really understand the goal in the program.

Right. Because then they're not going to accidentally jump too far forward, create a very negative experience. For that already super sensitive kid who then shuts down and won't eat.

Yeah. Yes. Because we have had some of those.

And those are not even just an illness. Right. Like getting the flu or cold can set some of our super sensitive kids.

Oh yes. Like four weeks, you know, four weeks forward is seven weeks back. Yes.

So frustrating for everybody, right?

Yeah, yeah.

But the more they're involved in the process and the more they understand it. And I'm not trying to teach them to be a speech pathologist, I'm just trying to give them a view. Because nobody looks at feeding. Right. It's easy to see when a child goes from, you know, laying to sitting, to crawling, to walking, but from, you know, suckle patterns to lingual transport to chewing, we can't see any of that.

Yeah, no, I think that's really helpful. Especially you know, you get like we've talked about before, you go to the pediatrician's office and they're looking for their specific markers. And so the family again is kind of going, but the pediatrician said he's fine. And it's like, but he's not fine. That's why you're here.

I think when he graduates from high school. School. Okay.

Yeah, I think it's a great. Exactly. Or I love when like, you know, mom's been doing all this work with a child and dad brings a child for a session and he goes, well, I have the same problem and I'm fine. And I'm like, but are you fine? Like if we actually break it down and how hard has life been? Can we make it a little bit easier for your child?

And let's talk in 20 years when you're snoring and your wife is about to like you up at night because your mouth breathing still.

Uh huh.

And that kind of goes back to that weight thing too. Even you know, I've had. So in Raleigh they had an obesity clinic and a lot of those kids came to me because they were the, the goal was to help them choose more healthy foods. But what I found was, you know, their weight was fine or too big or even if you're talking about a kid that's not obese, if you're just looking at it, typically chunky little kid or a regular sized kid, that doesn't tell you anything about the nutrition. They could be living on Doritos and Ho Hos for all we know. And that could be like one piece of vegetable, fruit or meat in their body. And so all of those kids had motor function and sensory based. They didn't like textures. And as soon as we got them comfortable with their motor and their sensory plan, they were super willing. I didn't have to do a lot of the kissing and playing around and messing around with food, because when their patterns worked and their swallows didn't hurt or get stuck anymore, they're super willing to try.

Yeah. Yeah. And it's so interesting, too, because I think it's more the opposite. I get a lot of, like, babies who are underweight or calling or kids falling off the weight charts. And, you know, when we do get the kids who call because they have a list, and then we do a myofunctional email, we tell them, well, you actually can't chew and swallow your food properly. But, you know, and the S will come along because we're going to work on this first. And the parents, like, wait, we came to you for a sound. What are you talking about? So we get a whole, you know, gamut of different types of patients. But, you know, I don't do the intake calls anymore. But every single time I would say to a parent, well, tell me about your child's diet. You know, like, what are their favorite food foods? What foods do they not eat that you wish they did eat? Or, you know, and they go, that's really interesting that you would ask. And then they start, you know, and they'll start telling me something. I go, so do they tend to like foods? Like, you know, I'll just list out some foods, and maybe they're more, you know, they might have some colors in their diet, but are they usually brown, beige, white, maybe some yellow, cheese, you know, and they go, yeah, yeah. How'd you know? This is what I do all day, every day. Like, this is just hand in hand with everything else you're telling me. So I just had this wild, yes, that might be the case. I know.

And usually I have parents that really want the children to move into the healthy foods. But I did have this one child, super picky eater. As he started getting more comfortable with his motor skills, he started wanting to transition into new foods. And he came into therapy, and they were all excited to tell me that he tried a new food. So I'm thinking, what vegetable did he try? Or whatever. He ate a donut. And I'm like, nah, I was hoping we were going, but so excited you tried a new food. I'm trying not to, like, be disappointed.

Poker face. Keep my poker face on.

But, you know, I guess I didn't do a great job of really understanding where that Family was nutritionally because I can't get him to ever eat broccoli if mom and dad never eat broccoli.

Right, right. Yes.

Yeah.

Well, and I think I also just being outside the D.C. metro area, we do have a lot of families who when they're calling us for some of these services and you know, also can afford to do the tongue tie release or put their child through expansion or you know, because we're working with babies through adults for the myos. You know, we're doing myo with toddlers. 4 year olds really should say on up. And then more of the feeding therapy is, you know, babies and the younger kiddos. And so I think I'm a little spoiled because I think a lot of our families do source healthy ingredients and if they can't get their child to eat broccoli, they're trying to figure out how can I get it into their diet. But you know, I do once in a while get a surprise with a family where I say I'll send a list of what I want them to bring to the evaluation. And you know, most of my families will come with like an organic yogurt and some organic or gluten free dairy free snacks or something crunchy, you know, and then I get the family that brings like Cheetos and soda. And I'm like, maybe I should be more clear. These are not whole foods. But they'll work for today's purposes.

That's the whole thing about meeting them where they are. Put our biases on them. We have to meet them where they are and then maybe through their experience with us, we can help expand. And that's not the typical patient that. I mean that one just kind of threw me out. I don't know that I've really experienced. Experienced that in like 30. The 30 years I've been working or. Yeah, very.

It's fun work that we do.

Love it. That's why we're here, right?

Absolutely. Absolutely. Well, this has been amazing. Is there anything else that you want to add that we haven't covered today?

Well, I'd like to talk a little bit about what you put in your mouth changes your function. And I'd like to talk about pacifiers for a quick session. No, I didn't put that on my.

No worries.

Let's chat.

I love that topic.

I was riding my bike this morning and I'm like, what would I like people to really know that to think about? And so, you know, we have. And I only have two of them right here for everybody to look at. I don't know if you can see them, but one. You know, people tend to get these kind of pacifiers because they're cute. And I just really am sad that these are so ugly. For me, these are more functional because especially for the population, I see almost all of them are compression dominant babies. None of them have great socks. None of them have really good tongue patterns. And so they like to bite the neck of these pacifiers and then their tongue just kind of hangs out and does whatever. And especially this orthodontic one, you know, the tongue into a retracted position. This one parents will say, well, I have that pacifier. They gave it to me in the hospital, or maybe not, but they don't like it. And I'm like, why do you think they don't like it? Well, because they keep spitting it out.

Because they can't hold it in their mouth.

Okay, well, let's look and see what they do. And I'm like, see? And then they get mad at it. And then, like, think about, maybe they're frustrated and they're not mad at the pacifier. They're frustrated that they don't have the supplement to enable them to keep that pacifier in their mouth. Because a lot of times what I see is when a baby can master this pacifier, they start using the correct patterns that make breastfeeding possible. So I'm like, this is just, you know, and you don't have to use a pacifier because I know some people are not about pacifiers. I think they have, you know, good qualities. I think if you're two, you should not be, you know, I think use a pacifier for six months or less, and then you start your exit plan.

And for people who can't see, who are listening, you're talking. You're recommending the soothy pacifier that's more rounded. You can put your finger in it. I use that with my kids. Although my first one didn't really keep pacifier in too long, but once she popped it out, we were like, okay, we're done. That was easy. And we used it. I actually use that therapeutically, too, to do paci pulls and to help bring the tongue forward and, you know, and really create the center, the rounding around that. And you can't do the same thing with those other ones that sometimes have cute little mustaches or whatever they put on them. Cute little pictures and sayings or whatever. They're adorable, but they're not. Or they're really not orthodontic.

So, yeah, they're Kind of like sippy cups. Right. They're made for parents.

That's right. They're cute.

They're made for pictures, not for function. Yeah, certainly. Yeah. And I like to use a pacifier a lot for a mom or a dad who just doesn't do a great job of reading a baby's cues. You have some parents that you can train, some great oral function work and they can go home and use that home program and the baby comes back looking great. And then there's some that you give them a little program and the baby's so hypersensitive because they didn't realize that when the baby's eyes lift up and they are pulling back and gagging that means stop, you know?

Right, right, right. They're like going further in and they're.

Like, why isn't this working?

Yeah.

Should I keep doing it if he's crying? No, no, no, no. I guess. I don't know if you have any other thoughts on that. I want to show you one more thing.

Yeah, no, go ahead.

Two more things actually. One second. I thought this was close. I want to look at different bottles because there, I think there's so much confusion and so much marketing about the best bottle for breastfeeding kind of thing. And my favorite, and I don't get any money from Dr. Brown's, they don't give me anything. But my favorite bottle is like that more standard nipple. This is not a Dr. Brown's nipple. I, I have those at work and I didn't bring them home.

I probably have one here. Keep talking, I'll go grab it.

And so I show parents like. What I like about a Dr. Brown's is if you think of your thumb is about the length of an infant's tongue. If you put the thumb like where that nipple sits and it sits about right on that middle part of your thumb and that's about where the hard soft palate juncture is or approximated. And if you take one of these fancy things and you put it here, they don't even get close to where that medial tongue would be. And so what can baby do? They have to bite, right. They have to use a bitey pattern. So all of those made for breastfeeding. And when I did a talk, I don't have it with me but I guess I could try to find it and maybe share it. I looked at all the different bottles and what they said they were most like breast and whatever, develop orthodontic and blah blah, blah.

There's the beautiful Dr. Brown's and that's, you know, and I think for people to see, one of the things I learned early on was that this is great because they can fit the whole nipple in their mouth and their lips rest against the base, the white base. Whereas most parents think, well no, it should rest against the nipple. No, this actually gives them some really great support especially for having feeding challenges.

And their lips flange really nicely on that even though it looks like a skinny bottle, but it's not. They flange way better than the skinny bottle, than these that don't provide. I mean it's like a, I mean, I guess maybe this could look more like a breast than that does, but it doesn't function like it at all.

Yeah, and I'm sure the doctor, some families, because a lot of lactation consultants around here will recommend some of the wide neck bottles and families will say, oh well we tried your recommendation with all Dr. Brown's and it didn't work. And this one works better than that on Valancino or whatever, you know, and I'm like, look, you use what works for you. I'm not saying one is better than the other, but I'm telling you that from what I've seen over, you know, in my experience is for a baby who has a normal feeding, you know, sexual liberty pattern and they're feeding well, this is the best that I've seen. And so for those children who also have, who have, you know, atypical patterns to try and get them feeding properly, this is going to give them the best support because it most mimics the movement that we want with, you know, it's not going to be the same as feeding from the breast ever when you're feeding from a bottle, which I think is a big misconception. Right. But you know, but this will give them the best support that a bottle in my opinion can give. Or you know, I know that there's the medical grade Dr. Brown bottles as well, which I don't have readily accessible right at the moment, but yeah, I like.

Well and if you hold that, you know, if you hold that bottle like a pencil and give the baby the jaw support and use a good firm jaw support and a little resistance, you can start activating. And I tell parents, especially my breastfeeding moms, let's, I know you don't want to use a bottle but for whatever reason you're on a bottle right now and maybe breastfeeding as well. But every time that bottle is used, let's use it as a therapy tool. Let's Train the best, most active tongue patterns that we possibly can. So then you feel better about being on the bottle. And hopefully that transition back to the breast is even faster. And here's a really interesting story. I had a mom that I had seen early on, and then the baby did really well, exclusively breastfeeding a bottle when mom was at work. And then mom called me when the baby was six months old and starting to teeth, and she said, you know, he is starting to rip me up when I'm nursing. And I said, well, are the caregivers still doing the bottle technique that I taught you early on? And she's like, I don't know. I have to check. And so she. She brought the baby in. I looked and I'm like, he's really more compression dominant than you want. That's why it's hurting. Let's make sure that they're using that. Those techniques that you did early on. And she called me back in a week and said, beautiful. It worked. Like the baby just continued to need those supportive procedures because now he's moving into a different transition period.

Right.

So you know that that was very helpful for her.

So Amazing.

Yeah. And then one more thing I want to talk about, if you're okay, is we have time.

We're good, we're good, we're good.

So pace bottle feeding.

Yes.

So I've done research on paste bottle feeding, and I have learned that there's not. It's kind of like we don't have.

A good.

Concrete way of analyzing tongue tie. There is no standard for paste bottle feeding. It was up to, you know, some would say like every 30 seconds, every 10 sucks, whatever, whatever. For me, as a speech pathologist working on coordination of sex while a breathe, my pacing technique is based on the baby's respiratory pattern and any other stressors that they're showing me through eyes, through eyebrows, through body movement. So I'm listening for that suck, swallow, breathe pattern. Or sometimes it's suck, suck, swallow, breathe. I want to hear that, like, pattern. And if I'm not hearing that, that's when I'm providing the pacing. Regardless if they've taken one sips, suck, swallow, breathe, or they took 50, you know, based on what that baby's telling me. Because I find that when you're bringing the baby upright and you're pulling the nipple out and you're putting it back in and you're relatching, for some babies, that sensory experience is too overwhelming. And also if you pull that nipple out and the baby has a mouth full of milk, they're more likely to choke. So I like to keep the nipple in the mouth and just bring the baby upright, make them take a breathing break. Once they realize there's no milk, they're gonna stop sucking. And remember, the only way to swallow air is to swallow. Okay, Just sucking. You're not swallowing anything. So you're, you know, everybody's like, oh, they're swallowing air. Like they're swallowing air when they're going to hard, uncoordinated swallows. Those are air swallows, right? And so if we can get them paced based on what the baby's telling us they need based, rather than like this random, I'm going to pace you every X amount of time or socks or whatever. Whomever decided what their definition of pace feeding is, I think then we can really do a better job of reducing that aerophagia and making baby more coordinated and give them more effective sucking patterns so that they can be successful breastfeeders or bottle feeders. Whatever they, you know, whatever the moms are choosing or the babies are choosing.

That's good. I like that. I like that tip. That's a really good one. Thank you. And, you know, it's so funny because I never stopped to describe it that way to a parent or to say, you know, But I would. I would kind of show them, like, this is how I'm going to pace your baby. Watch what I do. Oh, did you see? And the parents would say, oh, my gosh, like, his eyebrows are getting red. And I'm like, well, that's an airway thing. He's telling us that he's. He's not coordinated with his breathing. If we're not seeing a response somewhere on the face. And so what I've started what. Not what I've started. What I do with my families is I try to show them. Look at baby's reaction. If baby just looks calm, cool, and collected, like they. They're just, you know, like no big thing. Keep going. You know, they seem okay. If you hear that, suck, swallow, breathe, you can keep going. But if you start to hear, you know, suck, suck, suck, swallow, and you're not hearing the breath or they're. Because I've had babies too, where we question, do they have laryngomalacia? And one ent says yes and another ent says no. And I'm like, well, this is not helpful. And really, there's not much that we can do for baby at the moment if they're not going in for surgery other than help them feed the best that we possibly can and work on their motor and sensory system. So, you know, so it's. That is interesting because that is typically what I do is I kind of follow baby's lead and I tell parents, you know, pace as you feel like baby needs to pace. And let's look at this because, you know, every child is different. But you know, I can even think of one off the top of my head where he would just. And nobody else seemed to see it except for mom and I. And mom would take videos to be like, look, this is what happens. Like, you would see his eyes, like, you know, bug real big and he'd start seeing sweating and his face would get red blotches around his eyebrows. And you know, and when you start to see those things, that's, that's a good indication. You should.

Catch it before we get to the right.

Right, exactly. So now how do we prevent that from happening? And so I like that whole it's not every three suck, swallow, breathes, it's whenever baby needs it. I think that's a really, really good, you know, way of putting it. And versus, you know, I probably made it really complicated in my description going, let's just look at baby. And if we feel like baby is starting to have a hard time breathing, you know, give them a moment. And I like how you said you bring baby up too, rather than pulling the bottle out. Because I think when you pull the bottle out, baby tries to follow it and that's also going to throw the airway off because now what are we doing? We're sending them into.

Right.

So that's. I like that tip. Thank you.

And I think this is full circle, right? We've got the infant driven feeding.

We've got.

Got. To me, baby led weaning is really infant driven feeding, you know, helping them through those milestones, looking at their cues, what are they telling us? They may not be using words, but they are definitely communicating.

Yeah.

Well.

And I think Jill Raven and I just recorded an episode recently where she referred to it as modified baby led weaning. And I liked that too because I think, yes, there is some, there are some pieces of the program that I think can be helpful. But like you mentioned, there's also a place for purees and spoon feeding. And we need to make sure baby has the skills in place before we ever give them whatever it is we decided we're going to give them. So, you know, that's why there is a hierarchy and a progression in feeding. And that's why we typically recommend you Start with, you know, a puree and then make it a little chunkier and that, you know, before we just hand them a stalk of broccoli, you know. So, yes, I think most speech pathologists in the feeding world would agree with you that baby led weaning in a modified way. And really, I don't think baby's leading the way per se. I think that it's a partnership and we're really leading the way. But baby is telling us what they're ready for or not for and we're respecting what baby's communicating to us and that.

Making the choices.

Yeah, exactly. Yeah, thank you.

That's a good, good point.

Yeah. Well, thank you so much. This has been amazing. Any other last.

No, I know. I threw a bunch of stuff.

Oh, I love it. I think this will be great. And as I mentioned before, this will be obviously up on the podcast, but we'll also put this on YouTube so that everybody, you know can go and watch and see those amazing tips that you shared with us towards the end of the episode today. That was really helpful. We'll also put in your website and your YouTube channel. We'll put that in the show notes and anything else we discussed today, we'll put in the show notes as well. So everybody has access to all of that wonderful information.

Okay. And then I don't know that we talked about. I have another website, Feeding and Swallowing Academy. I have already recorded a 17 hour course for lactation consultants. And I'm not trying to make them be speech pathologists. I'm just trying to help them bridge the gap between what they need to look for so that they can make those referrals to someone like us that have the expertise and really get an understanding. Because I've taken the course and I've actually taught in Raleigh, two very well known lactation consultants did a course before the IBCLC took their exam. And I was lucky enough to have a day to present on these kind of things that none of them understand or even learn about. And I think it's so important that they at least get a glimpse of what you need to look for. Make things more successful.

Yeah, no, I think that is fantastic. So, yeah, we will put that in there. Swallowing or pediatric feeding and swallowing Academy.com will definitely include that in the show notes as well for everybody. And like you said, we all talk about, and I talk about this all the time, Team approach. Team approach. Team approach. But if you don't know why or when to refer to somebody else on the team, then there's no team approach. So I think that's really fantastic. And thank you for creating that because that's something that I will definitely share with lactation consultants that I, you know, that I collaborate with. I think they would probably find a lot of value in that.

Yeah. And I know you talk a lot about that team approach. And I tell you, you know, being in Raleigh for so long, I had such a great team, I didn't even have to think about it. Now coming here to Florida, where people don't even realize that there can be somebody that's not in a hospital intensive program that does feeding therapy, you're having to build your bridges and get your network. And I tell you, it's a lot of work.

It is.

But of course, something you need to do, and it's so rewarding just by learning new people and new perspectives. And we all have a piece of that puzzle. We just see it from different approaches, which is so awesome.

Yeah, well. And as my specialty has changed over the past 10 years and as I become more niche down in the feeding world and myo world, creating my team, some of it fell easily into my lap and then other pieces I'm still working on. And so while we say team approach, you know, we do the best with the resources we have at hand in the given moment. You know, the best can do for our patients. And, you know, just today I got another call from an orthodontist in D.C. and last week I got a call from an orthodontist in D.C. and a dentist the week before, and I'm going to talk to another dentist on Friday, and it's like they're slowly starting to find me, and it's like I don't know where I'm going to put all these people. But, you know, it's. But it's great because I think that the more we get this information out there, which was the whole purpose of me starting this podcast, the more people will even start to seek us out, because the more they'll realize, oh, there are other ways that we can help our patients. I don't have to do it all by myself, which I think is also sometimes a relief. So, yes, team approach. I say that like it's an easy thing, but it does take a lot of work to put that team together. So that is a very valid point.

And speaking of that, if anyone has a good airway centric ent in the Tampa, St. Petersburg, even Orlando area, if they could let me know because I'm desperately needing one to send some. Some kids and some things too. So I would if anybody's aware, I've already posted it on several different Facebook sites and I haven't had one person respond so.

Well, if anything comes through here, I'll forward you the email. Sounds great.

All right.

Well, thank you so much, Joan. It's been an absolute pleasure having you on today.

It's been wonderful getting to know you as well.

Yes, thank you. Thanks for listening to this podcast. If you want to hear more of.

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