Kids Are Not Small Adults: Why Pediatric Feeding Isn't Adult Dysphagia Scaled Down

Being licensed doesn't magically create competency. Exposure doesn't create competency. And knowing one piece of the puzzle doesn't mean anybody ever taught you how to see the whole child. Here's the question I really want you to think about throughout this entire episode. Is the thing I'm seeing the actual problem, or is it the result of another problem? Oh, okay. Because here I am, I'm an SLP, feeding is within my scope of practice. But being allowed to treat something and actually knowing how to think your way through a complicated feeding case are 2 very different things. And I wanted to understand the why. Why am I doing what I'm doing, right? Like, why is this strategy making sense for this child?

Welcome to the Untethered Podcast. I am your host, Hallie Bulkin. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner, and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up-to-date information in the orofacial myofunctional therapy, airway, tethered oral tissue, and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest posture: tongue up, lips closed, teeth apart.

Breathe through your nose.

Let's get started.

Hi and welcome back to the Untethered Podcast. I want to talk about something today that I think a lot of us have experienced but maybe haven't really said out loud. Graduate school did not prepare most of us to actually treat pediatric feeding and swallowing. And listen, this isn't me bashing graduate programs, right? You earned your degree, you passed your comps or whatever, you know, your boards or whatever you took. You learned a lot. But depending on your discipline, you probably got very different pieces of this if you got anything at all. You know, as an SLP, maybe you had a dysphagia course that focused heavily on adults with little to no pediatric feeding mixed in. And as we know, that's very different, right? OTs, maybe you got more sensory processing and motor development. PTs, you're often looking at posture and tone and stability and movement, right? We all came into this from different angles, but very few of us were taught how those pieces actually come together at the table, like how they integrate together. And then at some point, many of us were handed a child with feeding concerns and essentially told, when you're sitting here thinking like, Wait, what? I'm supposed to know how to do this? I mean, I personally remember that feeling, right? It was early in my career. I was working in the schools and I had asked them actually if I could have kids that had feeding goals and a mentor to help me. And they were like, oh, we don't do that in the schools. That's not what we do. I didn't know enough yet to probe further. And I was like, okay, well, I guess my day will come eventually, but right now, like, they don't do that here. But then a colleague went out on maternity leave and suddenly 12 kids with feeding goals in a very medically complex classroom setting, you know, where these kids had medical complexities. They were all in a classroom setting together. They landed on my caseload all in the same week, 12 kids. And I was like, oh, okay. Because here I am, I'm an SLP. Feeding is within my scope of practice, but being allowed to treat something and actually knowing how to think your way through a complicated feeding case are 2 very different things. So I researched. I shadowed, I took courses, I learned everything I could. And for a period of time, I was doing what I think a lot of clinicians do. I was working really hard doing things that made sense on paper and hoping the child would improve. And I didn't want to throw spaghetti noodles at the wall and just hope they stuck, right? I wanted to understand the why. Why am I doing what I'm doing, right? Like, why is this strategy making sense for this child? Why, you know, why I needed to look at one thing before something else. Why something wasn't working, right? And that's the gap that I really wanna highlight and talk about today, because pediatric feeding isn't one skill. It also is not adult dysphagia on a smaller person. Let's get that super clear. And that's the thing, a lot of us that had any education around dysphagia, right, swallowing, we had it through the lens of adult dysphagia, right? Oral phase, pharyngeal phase, esophageal phase, airway protection anatomy, instrumental assessments. All important information. We absolutely need it. And you could argue that this also is the same kind of order of events we might be interested in talking about and learning about with pediatrics. But pediatric feeding is not adult dysphagia scaled down, right? With many adult cases, we're also looking at a system that was functioning and then something changed. Whereas with children, we're often working with a system that's still developing. Their body is learning how to stabilize and breathe while the oral skills for eating are developing. Sensory experiences are changing, regulation is developing, and somehow all of those systems have to like come to the table and integrate and coordinate together. And they're doing all of that while their entire body is growing and changing, right? It's a very different clinical problem and presentation. And this is where I think the gap in our training becomes so obvious because also beyond just the problem and the presentation, when I say presentation, I mean like anatomy. Anatomically, physiologically, right? Kids are not just small adults. It's a different operating system. Things operate completely differently. Okay, so that's where I mean, like, when I say there's a gap in our training that becomes so obvious, like, we've learned these things in separate buckets. Okay, swallowing may have lived in one course, sensory and motor development somewhere else. Well, airway and GI and oral function got different amounts of attention depending on your program, if it got any attention at all. Maybe it was all post-grad. Grad information, you learned through paying through, you know, additional courses after grad school. But very few, few of us were actually taught how to kind of like take a step back and say, okay, so what happens when all of these systems belong to the same 2-year-old sitting in front of me refusing food? Like, that's the missing piece, right? We were given pieces of the puzzle. We weren't always taught how to put the puzzle together. So you may know that posture matters, right? But the deeper question is whether you're connecting what you see in the body to the oral skills you're asking for. You may notice chronic congestion or mouth breathing, but are you considering what that could mean for oral rest posture, for chewing or endurance, right? And if a child looks like quote unquote sensory, are you also asking whether maybe there's pain, GI discomfort, or limited oral skills, right? Like any of those things could be contributing to what you're seeing. Because here's the question I really want you to think about throughout this entire episode. Is the thing I'm seeing the actual problem? Or is it the result of another problem? Okay, because that changes, that question changes how you look at a feeding case. And I want to show you what I mean. Okay, so think about a 2-and-a-half-year-old who eats purees, dissolvable crackers, and maybe not much else, right? Anything requiring more chewing leads to gagging or refusal, right? So what do we see? We see texture selectivity. And naturally, someone might start working on sensory exposure, maybe food play, food chaining, gradually introducing textures. Taking the pressure off eating, and there can absolutely be a place for all of that. But let's pull back a little bit because this child's sitting at the table with their feet dangling. They're chronically congested. They're habitually mouth breathing. Their tongue is sitting low and forward, right? And when they chew, the jaw's doing most of the work with very limited tongue movement or lateralization. Now the case starts to look a little different, doesn't it? And we have to ask like, okay, is there a sensory component? There may be, but what if what we're calling sensory refusal is actually a child communicating like, hey, this is really hard for my body to do? Yeah, that's totally different, right? And if I spend 4 months in therapy trying to get that child more comfortable touching and tasting a texture without understanding why managing that texture is difficult, I may be doing really good work at the wrong layer of the problem. Why am I talking about this? I have seen this in play so much. Like, I have seen kids come to our therapy practice who have been doing food play for a year, and they have gotten no further than where they were the day they started. Okay, and this is why I say all the time that we have to look beyond the behavior. The refusal, the gagging, the limited food repertoire— it's all information, but none of it alone, like by itself, tells us why. So our job isn't simply to name what we're seeing. Our job is to get really curious about, like, what's underneath. Maybe this child needs better postural support. Maybe that chronic congestion needs further evaluation. Maybe we need to look more closely at oral function and whether the child actually has the skills necessary for the textures we're presenting. And yes, sensory work may still be part of the plan. Okay, we're not throwing sensory out. We're figuring out where it belongs in the order of operations for this child. That's clinical reasoning. And that is very different from grabbing a feeding technique and just hoping it fits. Okay? And I want to stop here for a second because I can already hear somebody listening to this and thinking, okay, so should I start checking every feeding kid for airway? No, that's not exactly the point I'm making. I mean, arguably, yes, maybe, but— But I don't want airway to become like your new hammer either. Okay? I don't want you to replace a sensory lens with an airway lens necessarily, or replace sensory with oral motor with tethered oral tissues, or suddenly decide every child needs to go see a GI or an ENT, right? That is not integrated care. That's just swapping out one silo for another. And so the goal is not to find one lens that explains every feeding child. The goal is to stop treating through just a singular lens to begin with. Okay, it's gathering enough information to figure out what exactly matters for this child, what's contributing to what you're seeing, and like what needs to happen next. And whether that's something you address or somewhere you bring another professional in, you know, that's a very different way of thinking. Because like, figure it out is not a training plan, it's not a treatment plan, right? And this is— I see so many clinicians get stuck here. When you don't have a framework for looking at a whole child and the case doesn't improve, You have to explain it somehow. So maybe you think like, oh, this is just a really severe case, or maybe the family isn't carrying enough, they're not carrying over enough at home, or maybe feeding therapy just takes forever, right? Or maybe I'm not good at this. And that last one, sadly, I hear all the time. Like, Hallie, I feel like I should already know this. But here's the thing, like, why? Because you're an SLP? Because you're an OT, a PT working with the same children? Like, Because somewhere along the way you got the message that you should already know all of these pieces and how they all fit together. Being licensed doesn't magically create competency. Exposure doesn't create competency. And knowing one piece of the puzzle doesn't mean anybody ever taught you how to see the whole child, right? Those are different things. And so many clinicians are trying to build these skills in complete isolation. Maybe you're the only person in your building working with feeding cases and there's nobody sitting beside you, say, like asking, Why'd you make that decision? Or challenging you to consider another explanation, right? No one who can say, hey, before you go there, I want you to take a look at this. Or even like, ah, I think you're moving a little too quickly. Like, we don't have enough information yet. But that kind of feedback, my friends, like that changes you clinically if you do have that. And so more information isn't always the answer. Okay? But this is where continuing ed comes in. Obviously, I love continuing education. I built a huge part of my career around educating clinicians. But information by itself does not create competence. Okay? You can take an incredibly informative course on sensory feeding, oral motor, tetheral tissue, airway, whatever it is, right? And walk away with some really valuable information. The problem comes when nobody teaches you how to integrate those lenses together, because whatever we just learned tends to become the thing we most likely see in therapy in our upcoming sessions. You take a sensory course and suddenly you're noticing sensory everywhere. You spend a weekend learning about tethered oral tissues, and now you're seeing restrictions in every mouth. And that's human, but the answer isn't replacing one lens with another, right? It's learning when each lens matters. And so I just go back to a course can give you information, but competence develops when you apply that information to actual children. You see what happens, you adjust your thinking, you get feedback and begin recognizing patterns across cases. That's when things start to change. Because eventually you realize that the same finding can mean 2 completely different things in 2 different children, right? One child can have a restriction that looks significant, like anatomically, right? The anatomy, it looks so, so restricted, and functionally they're doing pretty well right now. Another can have something that looks like, oh, it looks kind of mild or subtle, as people will like to describe it, which I don't love that, but that's how they describe it. But in the context of the rest of that child's system, it's having a Much bigger impact, like wreaking complete havoc on the child's system. Okay? One child's food refusal may be predominantly sensory, and others might look sensory until you uncover something else that contributed to why eating is difficult for them, right? And you stop asking, like, what's the protocol for this? And you start asking, what is the child telling me? Okay? That is the clinician I want you to become. Not someone with a bigger bag of tricks, but someone who knows how to think through a case. What information you still need, what you can address, when to refer or collaborate, and when you simply don't have enough information to make the call yet. Okay, that is confidence— not knowing everything, right? Knowing how to figure out what matters. And this is exactly what I want to start showing you. Okay, so September 28th through 30th, I'm actually teaching a free 3-day training called Screen the Peeds to Feed the Peeds. And honestly, this is why I want you there. Not because I'm gonna hand you another giant list of things to check. I want to start changing the way you think when a feeding kiddo walks into your room. We're gonna walk through the screening process that I actually teach, including how to use a screening tool to identify potential signs and symptoms and determine which areas may need a closer look or referral. And we'll talk about what the screening can and cannot tell you, like how to make sense of the information you're gathering and how those findings help guide what should happen next for that child. Because you can't determine the most appropriate next step, whether that's treatment, additional assessment, referral, collaboration, or simply just monitoring the kiddo, right? If you haven't gathered the right information first and you know how to implement it, right? That's where it starts. So if you have feeding kiddos on your caseload and there are cases where you're thinking like, I know something's missing here, but I can't quite put my finger on it, come do this with me. I also want to invite you to join if you're someone who's like, oh, I'm not sure feeding's for me or not. Join us. Or if you work with pediatrics, join us, because even if you decide pediatric feeding is not for you, it is still your responsibility to screen these kids if you have concerns and make the right referral. And I will teach you how to do that as well. Okay, so come hang out with us. Go to feedthepeeds.com/training and register for Screen the Peeds to Feed the Peeds. Like I said, it's free. We're doing it together for 3 days, and I want you there. Before you go, I do want you to try something, okay? Think about just one child on your caseload who isn't progressing the way you expected. And before you look for another activity or a strategy or a protocol, I want you just to take pause and look at that child again and ask yourself, what have I actually assessed? What have you assumed? Like maybe what have you not even considered yet? Okay, then I want you to ask, am I treating the cause or am I treating the thing the cause is? Created. Asking a better question is where better clinical reasoning starts. Okay. And if you want me to help you start asking those better questions, come join me September 8th through 30th for Screen the Peeds to Feed the Peeds. Like I said, go to feedthepeeds.com/training. I'll put it in the show notes for you here as well. So you can grab the link below this episode and just send this episode out to your friends, to your SLP, OT, and PT friends. You know, anyone who you think is working with pediatrics or who's ever looked at a feeding case and thought like, I know I'm missing something, right? Or maybe they've sent you some feeding trainings or things to watch in the past. Send this to them because chances are they were never taught how to connect all the pieces either. All right guys, I will talk to you next week. Quick disclaimer, all information, content, and material of this podcast are the opinions of the speakers and serves as the informational purposes only and not intended to serve as a substitute for the consultation, diagnosis, and/or medical treatment of a qualified healthcare provider.

Thanks for listening to this podcast. If you found value in this episode and want to hear more of these myotats, airway, and feeding-related episodes, be sure to leave a review on Apple Podcasts and share this episode on your social media platforms. You can access free resources and all I offer at halliebulkin.com or pop over to @holliebulkin on Instagram to get all the latest updates.