Episode 73: OMD’s and Birth To 3 with Hallie Bulkin

Hello and welcome to episode 73 of the Untethered Podcast. This is your host Hallie and I am excited to get back into chatting about myototsin Airway. So let's do it. 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. 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 bring you a topic today today that has come up quite a bit. We were launching the MYO membership this past week and we had a lot of questions about it. So I thought this would be great to chat about on the podcast. One I will tell you that I actually teach on this exact topic in Feed the Peds, but let's take a little dive into orofacial myofunctional disorders in the birth to 3 population. So we specifically had questions from therapists who work in EI and early intervention, if you're not familiar with EI as a terminology. And they were wondering if our MYO membership would be appropriate for them because they work with the younger kiddos. And MYO is traditionally a traditional MYO program is for four years on up. But here's the problem, right? Babies are born with orofacial myofunctional disorders. No one's really teaching that in introductory myofunctional therapy courses. This is why I actually specifically added both a MYO module and a TOTS module to our Feed the Peds course. Even though it's a feeding course, I think it's extremely important that everybody know that MYO is there at birth. And these children who need therapy at four things just tend to progressively worsen over time. But they were there since the baby was born. In fact, many times it was there in utero most of the time, I should say. Let's give an example, right? If you have a baby who's born with a tongue tie, well, what we do know is that that apoptosis or cell death, which you've heard me talk about on the podcast, plenty before basically failed to happen. And now the tissue under the tongue or that frenulum is tight. Right? Now we've got a baby who's born. We start to have symptoms. We're going to talk about what these symptoms are in a second. And what happened? Well, what happened was this. Had this apoptosis failed to happen. And this can happen down the midline in general. So if the tongue is tight, we should also be looking at other midline structures. Just as a side note, however they start swallowing, they being baby infants, right? Or the fetus, whatever you want to call it, start swallowing at 12 weeks in utero, right? So baby's still in mom's belly. Your belly, Mom's belly. And, you know, I say your belly because I know we've got mamas who listen to this. And baby starts swallowing at 12 weeks in utero. Now, what happens if you start swallowing and you're already compensating to do that even in utero? Well, now we have this pattern that is basically innate for this child, and it's not going to serve them well once they are out in the real world, right? So these babies are born with it. And I take issue with saying, well, we can't do a traditional MYO program with them until they're four. As if we should wait. Right. Cause that is a lot. No one's actually saying, oh, wait, wait, wait till they're four. I'm not hearing that so much. I'm just hearing this default answer of, oh, we don't do mild till they're four. I disagree. We can do my. And I've talked about this with Michelle Emanuel, who's been on several podcast episodes on here, so you can go back and listen to her conversations, our conversations that we had. But my message to you today is if you walk away with nothing else, do not delay therapy until four years. That said, therapy looks very different for a newborn or an infant or a toddler than it does for the four plus crowd. So that's what I want to do. Touch on today. I want to talk about the signs and symptoms of orofacial myofunctional disorders in birth to three. I want to talk about who's at risk of, you know, really developing bigger issues, and how do we stop that, that orofacial myofunctional disorder in this age group. Right. So we're going to take a little dive down into that in today's episode. So what I will tell you is if you're sitting here and you're like, well, who do I refer to? What kind of therapy is needed? Like, what do I do for this child? I want to help them, but I don't know how. What I want you to do is if you're not trained in this yet and if what I go over today in this episode is not something that you already do, please, please, please refer that infant. They are small, fragile infants. We can do a lot of harm if we don't know what we're doing. Please refer them to an slp, a speech language pathologist or an OC occupational therapist who, who can do feeding therapy, who specializes in doing like infant feeding therapy. That's very different than toddler on up types of feeding therapy and who has a background in orofacial myology and tots, right. Tethered oral tissues so that they can integrate what they know there into their feeding program. Because this child is probably coming to you. What is the number one sign or symptom that I get when a parent calls our office to have a child, you know, be assessed? It's feeding. Feeding is the big issue, right? They're having difficulty with nursing is usually. Or bottle feeding. It's usually the first sign. Poor latch on bottle or breast. The suck, swallow breathe is discoordinated. The tongue is unable to cup around either the breast nipple or the bottle nipple and draw milk in. There's impaired tongue range of motion. The tongue usually tends to rest maybe a bit too far forward during feedings. We'll see it like come past the lower lip or we might also just see the tongue rest between the lower lip, the upper and lower lip or even just that the mouth is open, their mouth breathing. We might see that tongue resting kind of forward and even off the lower lip a little bit. This is too far forward is the bottom line. We might see them sucking their tongue. We might see them. We might see lip blisters develop because of misuse of their tongue and different compensations they're trying to make to feed. Oftentimes these kiddos some other signs and symptoms now. So that's initially like the difficulty that we'll see with nursing and bottle feeding is the earlier signs. But then we move on to solids at some point, right. And we just, we see a lot of. First we'll see these kiddos have trouble with transitioning from like from breast to bottle, right? Say mom needs to go back to work at three months or five months or whenever and baby is making do with breast. But oh my gosh, baby refuses to take a bottle or just can't do it. And this is obviously very stressful situation. But this is oftentimes when some of these kiddos land in our practice and you know, three months, four months or so and mom is desperate to get baby to feed from a bottle because baby's going to daycare or with a nanny all day and mom's going back, you know, it's. She can't fathom her child not eating all day. But that appears to be what might be going on. Because this child refuses to take nutrition from something other than the breast, that can be a sign. We also tend to see open mouth postures at rest. Right. We also might see a high nasio label angle. They might have a diagnosis of failure to thrive. They may have gerd, which is basically reflux. But gastro, gastrointestinal. Gastrointestinal issues can be very common too. More so we might see that more so when they're actually on solids as far as like constipation might come into play versus like some gastro issues where they might be quote unquote colicky. Right. When they're still just on liquid feeds in those earlier months of life before any solids are introduced, you know. And then as I mentioned, once the food is introduced, we tend to see feeding challenges. So sometimes these are our kids who are described as picky or behavioral. Oftentimes I'll call them selective. If they're getting to a certain age where like they're on a self limiting diet, they're only allowing they're only eating a handful of foods that can be problematic. You know, they might have trouble transitioning to solids in general. And then sometimes we also see in more heightened and more severe cases gagging and vomiting. Like the gagging is normal. Ish. When they're learning to eat a new food, but it shouldn't continue. Right. If they're vomiting, that's not a good sign, especially if they're doing it, if that's happening regularly. Some other signs and symptoms. So we might see some issues with speech development. So there could be impaired sounds or maybe just delayed expressive sounds. So delayed speech productions. We're not hearing them use these sounds. And if they're using them, then their intelligibility may be impaired. There's a good chunk of sounds that we typically will see. Now obviously a lot of these kiddos don't have those sounds early on, but that doesn't. And I'm talking about like in a more traditional MYO sense. But that doesn't mean that other sounds might not be impaired. Right. So we really need to look at like what sounds are we having trouble understanding still? What should they have that they don't have? Are they doing, are they making compensations to produce this sound? We really want to be looking at all of that. And then I prefer to get the pacifier out of the mouth around four to six months of age. So I typically will say that we don't really want to see a ton of non nutritive sucking behaviors like oral habits kind of developing. They develop around six months or so. So I like to, I look at the 6 to 12 month window and I consider that a time to work on breaking some habits if we can. But definitely by 12 months of age, we should not be seeing any of those like mouthing of objects anymore or non nutritive types of sucking. Right. And then excessive drooling. That's another big, big sign or symptom of an OMD if they can't control the drool. All right, so who's at risk, right? Who's at risk for all of these things I just described? Well, newborns who are born with an open mouth at birth. A baby pops out and that mouth is hinged open. Oh, you better believe we got some work to do and we can help this child. That's the beautiful thing. And we should be doing this from day one, right, to make all of our lives a little bit easier. Because this child might actually be able to change their patterns since they're still so tiny and moldable and lead to better feeding, better speech production, better our speech sound production, I should say, more intelligibility. Right? Better, they say, better sleep already, better feeding, you know, all the things we've talked about. So who else is at risk? Well, any child, any infant or toddler we hear that has audible breathing. So it's not just snoring. Snoring also, but it's not just snoring. If we can hear them breathing, it's audible. That's a concern. You should not hear your child or a child breathe when they are sleeping, whether that's napping or nighttime sleeping. Our pediatric feeding patients, holy cow. They're a major risk for this. And that really includes even the littlest ones who are still drinking out of drinking from the breast or bottle, and especially those who have trouble transitioning to solids. Right? So we, we need to look at that. We also need to look at tots and midline defects, as I alluded to before, because those children are also at risk. Preemies, you know, we have to consider things like intubation if they were premature, how long they might like, were they in the NICU or not? How long really? We need to be looking at all of these things because this can impact the airway, which can impact other development. And we want to be looking at airway issues as a whole. We want to look at how baby breathes like we talked about before. The suck, swallow, breathe. Is that discordant? Is that not coordinated? Because if that's not coordinated, that's a sure thing that we need to address, right? Are there sleep issues? Babies this young, though, should not be sleeping through the night. And it kind of drives me up a wall when we have sleep specialists or I don't know what they call themselves formally, and I'm not hating on this as a profession, I am just simply stating that it's very dangerous to try to make your baby sleep longer if their body is waking them up for some reason. That reason it may not be hunger. And breastfeeding moms should never be forced to think they need to sleep train their child versus on demand feeding. I know there are sleep specialists out there who believe what I believe and who are educated in this. I'm not talking about you guys, but I see quite a few, especially in my area, who are constantly telling parents in Facebook groups that, well, your child is six months old. They should be sleeping through the night by now. And I'm over here going, is that baby breastfeeding still? Because that is some dangerous advice, especially if that mama thinks that that's what's normal, that they should be sleeping six hours tonight and that baby still is waking up every, like, I don't know, maybe waking up once in the middle of a night to feed. And they're being told, no, they shouldn't at 4 months of age, at 5 months of age, at 6 months of age, you know, so make sure you do your due diligence. Your due diligence. But also if your child is waking up that frequently, look at their sleep as a whole, but more connected to airway. Because if your baby's waking up, something is up. And we need to rule out airway issues. It's not a matter of training them to sleep. Babies will sleep until they need to wake up for whatever reason. Okay, enough about that. But that's a very big. That's a pet peeve of mine, if you will. All right, so digestive issues, that's another one. Medically complex infants, right? And we're talking again about who's at risk for orofacial myofunctional. Disorders. Children who are hyper or hypotonic. So they've got either their tone in their body's too high or it's too low. They're high tone, low tone, head shape issues. Rounded or protruded mandible. That's your lower jaw torticollis. You know, these kids oftentimes don't tolerate tummy time. Well, children who are using compensatory strategies already for their or to support their oral motor skills. And right now, that could be for breathing and eating and not oral motor for breathing necessarily, but definitely for, you know, eating if they are, and speed if they are already compensating. Like your antenna should be going up. If they have delayed speech or language, they're at risk. If they have delayed gross motor skills, they're at risk. If they are excessive drillers and you're switching out the bibs all day long, or they're oral sensory seekers and they're constantly putting things in their mouth, they are also at risk. Okay, so this is quite a list of kiddos that we really need to be taking a nice look at what when it comes to orofacial myofunctional disorders, and see if they have any of this going on. If they're on that list of who's at risk that I just mentioned. Now, how do we stop the omd? Okay, how do that? OMD being the orofacial myofunctional disorder. Well, assess, treat, monitor. Right? So let's break that down. We can assess oral rest posture. We want to see that tongue up in the mouth closed. Yes, that should be the case. As soon as they pop out. As soon as they come out of the womb, they should have a tongue resting in their palate, mouth closed, nasal breathing. Okay? And obviously, we want to assess for the oral rest posture. We want to assess for nasal breathing. We want to assess for tots. And it drives me up a while because in places like Brazil, they have a. They have a tongue tie screening at birth. So you guys know, you know, I know everybody. If you've had children here, and maybe if you haven't, but you're an SLP or the speech pathology profession, you know about universal newborn hearing screenings, right? Baby is born. Everybody. Every baby gets a hearing screening before they leave the hospital. And let me tell you, with one of my kids, they had to come back, and they had to come back again. And then they had to wheel her. And this was Lily, actually, Mrs. Tongue Tie. They had to wheel her down to the auditor, the audiology. They had Asked me if they could take her down to the audiology lab to actually do an ABR on her and test her hearing, because one of her ears was just not responding. She was totally fine. But like, that. I mean, that was an interesting experience, right, as an SLP and going, like, please, yes, do check her. I want to make sure nothing's going on. But also very interesting, you know, that they do that as a newborn screening. Why are we not screening for tongue ties and lip ties and buckle ties at birth? It literally takes, like, 10 seconds to put your finger in there, feel for something, lift the tongue up, pull the cheeks out, look under the lips, top and bottom, and really just make sure that we don't have any concerns. Not that we're gonna diagnose every child who might appear to have a tight one. If they're feeding well, okay, great. But if they are having struggles feeding in the hospital and you've given mom some lactation support and she's still struggling or still, you know, telling a mom, it's not gonna hurt in two weeks, Just give it some time. Or you're new. You just got to get used to it or what? That's not helpful, and it's false information. Okay. We should be doing these screens at the hospital. We should be educating and empowering our mamas. But that's a topic for another episode. All right, so then that's assessing, treating. Well, obviously, we're going to want to figure out and treat the root cause of the symptoms that are impacting, you know, successful feeds. Like, what is getting in the way of us successfully feeding this baby and in the way of this baby sleeping, in the way of, you know, them growing and really experiencing the quality of life we would expect for a newborn, an infant, a toddler. Right. We want to make sure. And that also goes for the parenting side of things, too. Like, obviously, toddlers are challenging. I have a two and a half year old, you know, and Lily's five. She wasn't. She's not so far removed from being a toddler. They can be challenging. They come into their own, and they know, like, they have a say in the world. Right. But that's very different than what we're talking about here. From a quality of life standpoint, if that child is vomiting and gets kicked out of a pool, Okay? I heard this in the MYO membership this week. There was a child who is no longer allowed to go to the public pool because he vomits too much. That is impacting this child's quality of life. If this Child can't go into a lunchroom, which I know schools are mainly closed right now, but humor me here, if that toddler can't even enter. And although I will say some daycares are open, so I retract that partially. But if the child can't eat at school or the child can't sit in the room and eat with other peers, because it's of the sensory aspects of being in that space or whatever, right. That is a quality of life change for this child. That is important to know. And that is also considered something that would be worth, you know, treating. Something that would be worth looking further into and figuring out, like, what is the root cause behind this? Why is this happening? So that we can treat it. Okay, and then monitor. Right. We want to monitor facial growth. We want to monitor posture. And that's both, you know, like, we're looking at neck, back, shoulders, this, you know, when I say the back, like, look at the spine. Is it. Is it nice and up and down and straight, or do we feel like the child starting to get a little torqued? And the neck, like, do they appear to have some unresolved torticollis? Do they have a side preference? Does their head tilt a little one way versus the other? Really looking into that type of posturing, as well as monitoring oral rest, postures and swallowing, what is that looking like? We want to monitor their developmental milestones. Oral motor, feeding, gross, bimotor, remember, also going back to postural control and posture, remember that it all is. It's basically like we always say, like, what you see here is what you see there. And that has to do with the core and the mouth. Some people will say what you see on the hips is what you see on the lips. Basically, just kind of demonstrating that our torso area is really the base for feeding. Like, we need some good support there in order to support feeding. Everything that goes on above that grand station down there. So bottom line is we need to be looking at posture. We need to remember the importance of postural control at the core because it is tied to our mouth's ability to do its job and do it well and fully supported. And we need to monitor sleep, we need to monitor saliva control, especially if there is drooling going on. And if the parent feels like, well, maybe it's happening because of teething, maybe, but that should end pretty quickly, right? So let's monitor that. And then dental eruption, that's another big one. Sometimes there's delayed dental eruption. Well, why is that happening? Is something going on with the bite is a tongue resting in the wrong place. Like what? Is there something that we can possibly help with that is in the way of more traditional dental eruption? We don't move teeth, we don't do dental types of things, but we can work with the tongue. Right? And I'm talking about oral facial myologists and feeding the therapists. We are not in the business of moving teeth. We are not dentists. And so, yeah, so just be careful how you approach that or discuss that, you know, with a parent. But. Or if you are a parent, FYI. But basically, dental eruption can be impaired by the oral rest posture. Okay, so definitely something to look at. So what are my recommendations for you? Right, let's wrap this up. Well, breastfeeding is ideal if that is mom's desired form of feeding. If not, then you bottle feed and you better help that mama figure out which bottle is going to work for her baby. Right, but that also comes with an entire treatment plan and working, doing some oral motor work, also doing lots of tummy time. Right? We want them on their bellies, we want them learning how to use their head and their neck, hold their head up and gain better control. But if there's torticollis in place, this may be uncomfortable for them and so that you might see some resistance. Okay, but again, that's a sign and symptom of an omd, isn't it? So what can we do? Right, so breastfeeding, as I mentioned, lots of tummy time, transition to a modified baby led weaning approach. So if you're someone who has started with just using traditional baby led weaning, which means there's like no spoon involved, there's no purees, basically not no spoon. But you're not feeding your child. I encourage you to transition to. And this is, this is Jill Raven's term, modified baby led weaning. We actually talked about this on episode 31 of the Untethered podcast, so you can go listen to it. But babies, children, they need a combination of puree and you spoon feeding them while also allowing them to explore safe foods, textures and presentations. Right? Pacifier. Right? You guys know, if you've followed me for any short period of time, you know what I think about some of the PACs out on the market? Either way, if you do use them out by four to six months, six of the latest is ideal because that's when habits form. And we don't want that to have form into a habit. We want to provide appropriate oral tools for exploration based on their age. You know, appropriate for their age and their development level. And then we want to introduce open cup and straw cups by six months of age. Right. Weaning from the bottle, if they're using a bottle, by 12 months. So this last list of recommendations I gave you are things that you can absolutely start putting into play now that will help benefit better orofacial myofunctional development. Right. Because the goal is if they're born with an omd, an orofacial myofunctional disorder, whether it's a tongue tie or there's something else going on, one of these other signs or symptoms that we talked about, we can absolutely do passive therapy and start to work towards the overarching goals of mayo with, you know, mouth closed, tongue up, nasal breathe, you know, eliminate any sucking or oral, I should say noxious oral habits. We should eliminate, be eliminating those, you know, so that is, those are the kinds of things that we can be doing. But that should come from you as the therapist on the team where you can say, hey, look, I'm assessing for oral rest, posture, tots, nasal breathing right now. Okay, I found X, Y and Z. We're gonna, you know, I think that's being caused by this. So let's treat the root of the problem here. We're gonna work on this so that we can get back to successful feeds and successful sleep and successful growth and, you know, a great quality of life for the infant and the parent or parents. And yeah, and then we're gonna continue to monitor these things like I talked about, like facial growth and posture and developmental milestones, sleep, saliva control, you know, dental eruption. We will monitor all these things. Right? And so there's, there's definitely things that we can be doing. And that's what I wanted to open up your eyes to today. I hope this is helpful. Go back, listen, you know, take notes. But also I put this all nice bulleted point bullet points completely detailed for you in the show notes. So grab the show notes for this one if you want. Just a nice PDF of what are signs and symptoms of OMDs in 0 to 3 year old children. Who is at risk for an OMD? How do we stop the OMD? What does that assessment, treatment, monitoring look like and what are next recommendations if you want that grab the show notes. This has been so much fun talking to you guys because I love all things myo. And if we can stop it in its tracks in these little ones when they are newborns or early on in their infancy, Holy moly. We will be looking like we will be looking at a very different future. So my goal is to work on these babies while they're still babies and they're so moldable and give them the best possible opportunity at having a nice open airway and having, you know, nice developed jaws and all their other skills that they're developing. So I could talk about this all day. I love this topic, but let's get out there. Let's help our babies. Let's not be waiting until they turn four, right? And as you start to work with them and you keep in mind what your feeding goals are, and you keep in mind what your MYO goals are, you're going to start to realize how much they actually go hand in hand. And it's almost hard to tease out, well, is this a MYO issue or might this be feeding issue? Or I mean it really doesn't matter so long as they have a nice oral rest posture, they are swallowing properly, right and they're not experiencing all these symptoms we've talked about today. So that's the ultimate goal. I hope this was helpful for you all. I'd love to hear some feedback on it and let me know. We've got some great guests lined up coming in our upcoming episodes, but let me know who else you want to hear from, what topics you want to hear more of. I love inviting individuals on the podcast that you all specifically request, so go ahead and email us. Let us know what you think, who you want on the podcast, and what you think we should be talking about. We'd love to bring you more of what you all asked for. Those are always fun to record. Hope everybody has a wonderful rest of your day. We will chat soon. Thanks for listening to this podcast. If you want to hear more of these MYO Tots, Airway and feeding related episodes, be sure to leave a review on Apple Podcasts or pledge a small amount on patreon.com the Untethered podcast. If you found value, others you know in this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook on my Facebook page @HALLIEBLCAN BIZ, on Instagram at Alibulcan, and you can head over to theuntetheredpodcast.com to grab a copy of the Show Notes where you can also subscribe to be kept up to date on the latest podcast episodes.