Strategies vs. A Plan: Why Feeding Therapy Feels Like Guesswork

Same symptom, different story. That is the part we were not always taught to slow down and find. One of the biggest gaps I see in feeding evaluations is that we collect information, but we don't always know how to connect it. We collect it, but we need to connect it. We note that the child mouth breathes, they slump in the chair, they gag on certain textures, they take 45 minutes to eat, or they've got a history of painful feeding. Every item gets written down, but it still sometimes sits in its own little box. The magic is not in noticing more things just to create a longer report. The magic is in asking, could these things be related? And how might that change what I do next? 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. Okay, I wanna talk about something I hear from clinicians all the time. Hallie, I feel like I'm winging it. I know the child needs feeding therapy, but I'm not always sure what to do next. Oh, I got strategies, I got activities, I got foods in front of me, but I don't know if I'm actually working on the right thing. And usually this is not a clinician who does not care enough to learn. It's the clinician staying up late reading research, taking courses, trying so hard to help the child in front of them. So the problem is not that you're not smart enough. It's not, let's be very clear on that. And it's probably not that you need one more random strategy. What's usually missing is a framework, a repeatable way to look at the whole child, organize what you're seeing, decide what matters most, and then choose your next step with intention. Because feeding therapy should not feel like throwing spaghetti noodles at the wall and hoping one of them sticks, literally or clinically. Welcome back to the Untethered Podcast. I'm Hallie Bulkin. For hundreds of episodes, we have talked about the connections between feeding, speech, airway, oral function, sensory regulation, posture, movement, and the nervous system. Not because every child has a problem in every system or because we need to become every kind of provider. This is because feeding does not happen in a silo. When we only look at the presenting symptom, we can miss the reason that progress has So today I wanna talk about why feeding therapy can feel so overwhelming, what might be missing from the way you are evaluating these cases, and what changes when you begin using a more structured clinical process. Let's start with a case that might feel familiar. 3-year-old, they're eating crunchy crackers, but they're gagging on soft foods. Toddler eats 5 beige foods and the family's been told to keep offering new foods and wait. I don't like that word. You sit down with a child and you may have several ideas. Maybe you work on exposure, you try some oral motor activities, you change a texture, Or that you coach the parent to take the pressure off. None of those things are automatically wrong. Like, let's be clear about that. The problem is that they're not a plan until you know why you're choosing them. And that is where I see clinicians get stuck. They have the tools, but they don't yet have a process for deciding which tool belongs in this case with this child at this point in time, right? And when we don't have that process, every difficult session can start to feel personal. We think, why is this not working? Am I missing something? Do I need a different activity? But feeding is a complex motor, sensory, physiologic, relational, and learned experience, my friends. Mouth matters, obviously. The jaw that lifts the tongue, chewing, bolus control, swallowing— these things all matter, but the mouth is not floating around by itself. The child must be able to breathe, remain supported enough to use their mouth efficiently, stay regulated enough to interact with food, and tolerate what happens after they swallow. And we have to remember they bring past experiences, medical history, family dynamics, hunger patterns, sensory preferences, and learned protective responses. These things all come to the table with them. So when we reduce a feeding concern to they just need more exposure, or we need to strengthen the tongue, we may be naming one piece without understanding the whole story. That is why 2 children can look similar on paper and still need completely different plans, right? 2 children may both refuse meat. One may not have the chewing skill or endurance for it. Another might be overwhelmed by the texture, or they're avoiding it because eating's been uncomfortable, you know, and maybe even another has learned that meals are stressful. So refusal begins before the food even reaches the plate, before they even know it's gonna be served to them. Same symptom, different story. That is the part we were not always taught to slow down and find. One of the biggest gaps I see in feeding evaluations is that we collect information, but we don't always know how to connect it. We collect it, but we need to connect it. We note that the child mouth breathes. They slump in the chair. They gag on certain textures. They take 45 minutes to eat, or they've got a history of painful feeding. Every item gets written down, but it still sometimes sits in its own little box. The magic is not in noticing more things just to create a longer report. The magic is in asking, could these things be related? And how might that change what I do next? That is clinical reasoning, and clinical reasoning needs structure. Okay? So the first place I would look is the child's foundation for feeding. Before you ask the mouth to perform a highly coordinated task, look at how the rest of the child is showing up. Like, how are they seated? Are their feet supported? Can they maintain the stable position? Are they using all of their energies just to keep themselves upright? What happens to the head and the neck when they chew or drink? How are they breathing during the meal? Can they breathe comfortably through their nose, or do they need frequent breaks to breathe through their mouth? Do you hear congestion? Is there snoring in the history, noisy breathing, or other signs that maybe deserve a closer look or even a referral? And what is their state when the food appears? Like, are they curious? Are they hesitant but still like present and available? Or is their body already going, nope, this does not feel safe, right? We are not diagnosing every system during a feeding eval. We are screening, right? We're noticing what may be influencing performance, deciding what is within our scope, and recognizing when collaboration or referral is needed. That distinction matters, okay? And integrated care does not mean doing everyone else's job. It means you stop pretending that everyone else's piece has nothing to do with yours. And once you understand the child's foundation, then you watch real feeding, not just isolated movements, not just whether the tongue can move left and right on command, not just whether the child can close their lips around a tongue depressor. You watch the child eat and drink because a skill in isolation does not always tell you how that skill functions during a meal. It's really more like a screening, right? And a child may show adequate tongue movement during an oral mech exam and still struggle to grade and coordinate and sustain that movement with real food. So we need to assess further, which is why I always talk about this difference between like screening and assessment. You might call it assessment, but are you actually assessing? Maybe they drink successfully for the first few sips while you watch them drink, and then they lose coordination as the task continues. They may also chew one preferred crunchy food well, but then struggle when the texture becomes softer or denser or mixed or less predictable. The functional context around these things matters because what you're looking at— safety, right? Efficiency, coordination, independence, and what changes across textures, right? Utensils. Positions, environments, emotional states, right? All these things. And then we also wanna look for patterns. Not one dramatic moment that sends you down like a rabbit hole per se, but like patterns. When does the difficulty happen? What makes it better or worse? What can the child do when the demand is lower? Where does the skill begin to break down? That gives you much better information than a checklist of disconnected observations. Okay? And from there, you begin to identify where the greatest barriers might be. And I wanna be really, really clear here. Most children with complex feeding concerns do not have one neat problem with one neat solution. There may be multiple contributing factors, but that doesn't mean that you treat everything at once either, right? It means we have to prioritize. So we basically go, okay, let me ask you a question, right? What is most likely limiting progress right now? That is a question you're gonna ask. Is there a safety concern to address first? Is the child physically capable of the skill I'm asking for? Really important we don't skip asking that. Okay, we need to be asking ourselves this: could pain or discomfort be involved? Does another provider need to be a part of this plan? Which change, if I made that change, help this child make this change now? Which change would make the next skill more available? That is how a treatment plan stops being a collection of activities and becomes a clinical plan, right? So let's say a child is sliding out of the chair. They've got no foot support. They lose control as chewing demands increase. Your first move may not be another tongue exercise. What might it be? Before I tell you, just, I want you to think and I want you to trust your gut. If your gut was like, ooh, I need to improve seating and collaborate around postural support so the child has this better base that they can then use their jaw and tongue from, ding, ding, ding, you're correct, right? If a child is chronically congested and they're mouth breathing and they're unable to coordinate longer sequences of chewing without stopping for air, repeated food exposure alone is not gonna be your solution. That's not the whole answer. Right? You might need to document what you're seeing and then refer for the appropriate medical eval while adapting the feeding demands that are currently in front of you so the child can, you know, function. If the child's got a history of pain or reflux or vomiting, or maybe they've had really scary choking events, we cannot separate skill from trust. And arguably, we can't do that with any of our feeding kiddos. We have got to build trust and rapport from the get-go, or they're never going to do anything that we want them to do because we're asking them to take risks. And those risks are scary and very unsettling to their nervous system, right? So you may need to reduce pressure, support regulation, rebuild predictability, coordinate with medical team while you figure out what the child can safely and comfortably manage. Okay? And yes, sometimes the primary limitation is oral skill. Sometimes a child needs direct support for chewing and bolus formation and cup drinking and, you know, using utensils or other functional feeding skills. But now you know why you're working on that. You know what you're measuring, you know what would count as progress even, and you know what you'll reconsider if progress doesn't happen or it starts but then stops or slows down, right? That is the difference between just doing exercises and practicing clinically. A structured approach also protects you from one of the easiest traps in feeding therapy, which is chasing the symptom, my friends. The child gags, so we target gagging. The child refuses, so we target refusal. The child pockets food, so we cue them to clear the pocket. But the symptom, that's just information. It's not always the place to begin. Gagging may be related to skill or sensory processing or pacing or texture, fear, airway, gag discomfort, tethered oral tissue, or a combination of factors. Okay. Refusal may be communication. Pocketing might reflect reduced awareness. Maybe there's inefficient chewing or fatigue. Maybe there's just like limited tongue movement happening. Maybe they're taking oversized bites, which a lot of our kids do when they feel like they can't manage a smaller bite. It seems so counterintuitive, but here we are, right? It's what they do, especially with tethered oral tissues, or maybe Maybe they've tried to eat a food that they're not ready to manage, and so they pocket it, right? When we only try to make the symptom disappear, we can miss what the symptom is actually trying to communicate to us, right? So instead of asking, how do I stop this behavior? I want you to ask, what is this behavior showing me? That one question can change the entire direction of a session. And this is also where we move from reactive care to proactive care. Reactive care says, the child is struggling with this food, so let's find a strategy for this food. Proactive care says, let's understand the pattern before this becomes a longer, harder, more serious problem to treat. It looks at the child who's coughing, tiring, they're avoiding, they're compensating, it feels like they're falling further behind, and we go, what deserves a closer look right now?

Right.

It recognizes that early support is not about labeling every difference as a disorder as well. about noticing when the developmental trajectory is changing and responding before the family has spent years being told to wait. Please don't do that. Please don't make these families wait. And here's the other thing. When you use the same framework across cases, something else happens. You start building pattern recognition, which I always thought was something that everybody had, but apparently just very innate to me. And so people will be like, Hallie, how do you do this in therapy? And why is it that you have such success with kids? And You know, your family stay and they complete therapy and the kids make quick progress and so on and so on and so on. And I was like, well, doesn't everybody just like have this intuitive like nature of knowing like this is what the kid needs based on their energy and their performance right now? And I know this may sound kind of woo to some of you, but I realized I had a framework I'd put in place without realizing it. And I had built pattern recognition. I'm really good at seeing patterns and then trusting that, you know, my gut, that we gotta go with that. That's what we need to be targeting right now. Let me give you some more concrete examples. You know, you notice that a child who can't manage the chewy textures is using very limited jaw movement. Okay, maybe you notice that the child who melts down at the table arrives super dysregulated. They come to the table dysregulated, and they've been grazing all afternoon, like they're not going to be hungry to eat. And they're like, in no place are they ready to be available to us either, right? You notice the months of exposure have not changed the fact that another child still looks really uncomfortable after eating. They look uncomfortable after eating. It's done. Why do they look uncomfortable now? Right? So the framework does not hand you a single answer. I wanna be clear about that. It just helps you ask better questions and better questions lead to better decisions. And that is how we actually develop our confidence. Not because you memorize every diagnosis and you never need help and every case becomes easy, cuz that's not true.

Okay.

Confidence comes from knowing how to think when the answer is not so obvious. It comes from being able to say, hmm, here's what I'm seeing. Here's what may be contributing. Here's what's within my scope. Who else might need to be involved? And the next best step is X, right? That's a very different kind of confidence than pretending like you know everything. Please don't do that. I've never pretended like I knew everything. In fact, families, I tell people this when we do our 3-day training for Feed the Peas. I always tell everybody that parents really appreciate when you don't know everything. You say, hey, you know what? I'm not sure about that, but let me talk to my colleagues and get back to you. The fact that you are saying, hey, I don't know everything. It's refreshing. It is refreshing for medical providers not to BS you, gaslight you, and make stuff up. It's also really nice when they go, oh, you're going to take time out of your schedule outside of the session to figure out something that could benefit my child? Like, when you start to look at that frame, right, you reframe it and go like, oh wow, I'm actually going to be working on stuff outside of this session and it's benefit you and your child. Parents appreciate that. Okay, so here's the thing. Don't pretend like you know everything. None of us do. I don't even know everything. So if feeding therapy has felt like guesswork to you, this is what I want you to take away. You probably don't need more random activities or strategies or exercises or whatever, okay? You need a repeatable process. And I want you to start with the whole child, watch feeding functionally, look for patterns across systems, prioritize the barriers that matter most, treat what is within your scope, collaborate when the story extends beyond your scope, and measure what changes when you can, okay? That's how we stop throwing those strategies at symptoms and Again, making decisions with intention behind them. And my friends, that is the foundation of Feed the Peeds. I created Feed the Peeds because clinicians were asking for more than just information. They wanted to know how to assess and connect what they were seeing, choose treatment priorities, build a plan, and know when to treat, adjust, collaborate, and refer. And at the end of September, I'm actually hosting that free 3-day training I was just mentioning. I'm gonna host another one from September 28th through September 30th. We're gonna walk through through the foundations that help feeding therapy feel more organized, more intentional, and a whole lot less like guesswork. Okay, so you can get on the waitlist at feedthepeds.com/training for that 3-day training. And before you go, think about just one child on your caseload who is not progressing the way you expected. Maybe it's not the easiest case, the one you keep thinking about after the session ends, right? I want you to ask yourself, have I been treating this symptom? Or have I stepped back far enough to understand the whole story? That is where I would start. Thank you so much for being here. I will see you in the next episode. Quick disclaimer, all information, content, and material of this podcast are the opinions of the speakers and serves as 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 MyoTots weight 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.