The Secret World of Oral Habits: Survival Over Phase

why these habits develop in the first place. Because the question isn't always like, how do we stop the habit? It's often, what is this habit trying to tell us? I want that reframe to be very solidified by the end of our time together today. Let's first start with talking about the gap, the gap that they just don't teach. Because here's the thing. Okay. Grad school, School did not prepare really any of us for pediatric feeding. I think there's maybe, I can count on less than two hands the number of graduate programs that teach pediatric feeding and swallowing. A lot of programs are focused more on like, you know, dysphagia in adults and not so much in pediatrics, which is unfortunate. And we're really hoping that changes, but in the current reality, this is what we're dealing with, right? So it didn't teach you then, right? How to assess a toddler who's refusing solids. Show you how to screen for tethered oral tissues. It didn't give you tools to adapt myofunctional strategies either for the birth to 5 population. You know, those kiddos who are not appropriate yet for a traditional myofunctional therapy program. Because even if you are lucky enough to go to one of those programs that does teach pediatric feeding, again, there's maybe, I don't know, I think 6 of them total that I'm aware of. Hopefully there's more out there that I don't know yet. But if you were lucky enough to go to them, they are not talking about tethered oral tissues and adapting myo strategies for the birth to 5 crowd. But these are the kids that are showing up on your load, right? So what happens? You're left Googling, piecing things together from Facebook groups. Maybe you're watching random YouTube videos, but you feel like you're missing something big because the reality is that nobody who is ethically providing information out there is showing you how to do therapy with exercises and all of that on social media or on YouTube. Because hi, that's unethical. And every child's therapy looks different, right? So we can't just go plaster exercises out there for you to follow. We can educate, right? But education can only go so far. Again, you're left trying to piecemeal it all together yourself without the appropriate mentorship and guidance and, you know, frameworks and information that allows you to actually step into critically thinking about these topics. And so that, my friends, is why so many therapists tell me, like, I know I need more, I just don't know where to get it. Like, I know— I knew I needed more, right? I just didn't know where to get it until I found Feed the Peeds. One of the biggest red flags— and I really don't love that term, red flags, but I feel like everyone knows what that means, so we're gonna roll with it— one of the biggest red flags for a possible tethered oral tissue, right, in toddlers, for example, is messy eating that just doesn't seem to improve. Okay, we get parents who say to us a lot, and maybe you have too if you already work in PEED feeding, they'll go, oh, they're just a messy eater, you know, oh, their food just falls out of their mouth, or I was just always like, you know, off the plate, on the side. And listen, I know adults like this too, but here's the thing, if you look closer, the tongue might not be lateralizing properly, right? It might not be moving side to side. That's what I mean when I say lateralizing. Maybe they're— the food is pooling in the cheeks, right? They've got those cute little chipmunk cheeks, and it's not always because they still have the baby fat there. It's because those chipmunks are storing food in the cheeks, right? They've got those little chipmunk cheeks holding food, and it's not because they want to. It's because they're struggling to clear it properly. And instead of chewing efficiently, a lot of times these kiddos are mashing up food, right? Show you what I mean by this. Okay, so they're doing more of this like up and down munch, right? The tongue might not even be moving. The tongue, like you see in this example, might be living on the floor of the mouth, and they're just going up and down, up and down, up and down. Mash, mash, mash. So when I say mash, they may not even be moving the food to their molars, to their teeth. The food may just be existing wherever they put it in their mouth, or it might be moving to their tongue and staying there, and they're literally mashing their tongue up against the roof of their mouth. I want to be very clear here. I wanna make a very critical, if you will, clarification about myofunctional therapy because this is something that we see causing real harm. And I've said this for the past, mm, 5 years. Traditional orofacial myofunctional therapy is an active therapy. It requires certain level of cognitive development, okay, to have happened, certain cognitive level, if you will. Generally, you have to be at least age 4, but arguably closer to age 5 cognitively. Like not just like, oh, we turned 5 years of age. Like, no, this child needs to be able to follow multi-step directions, the steps, the directions we would expect a 5-year-old to be able to follow. Because even then, sometimes a MYO program could be a little tricky for them. Infants and toddlers do not participate in traditional myotherapy programs. When we work on these similar goals in younger children, which is possible, we can take MYO and adapt it. Our approach is passive, it's developmentally appropriate, and it falls under the scope of a pediatric feeding therapist or pediatric feeding therapy. Okay, so only appropriately trained and licensed SLPs and OTs, and in some cases there might be PTs as well, that have pediatric feeding expertise— only these professionals should be providing and billing for this type of intervention. I said what I said. That is what is legally and ethically appropriate, and anybody else who's trying to sell a MYO program to young children or for education, it's a money grab. Again, I said what I said. It's unfortunate, but we are seeing many children get referred to providers who are not trained or licensed to work with this population. And so in some cases, children are receiving inappropriate treatment and we're actually seeing their symptoms worsen. Sometimes they're just not improving and it's very expensive in time and finances. Other times the symptoms actually get worse. So please do your research, ask about credentials, ask about experience with infants and toddlers, ask about, like, when I say credentials, not just like, oh, they say they're certified trained, but like, are they licensed as an SLP or OT if they're working with your child and your child is under the age of 5? Also, are they licensed as an SLP, OT, PT, RDH, or dentist if they're over the age of 5 and providing myo? Because there's a lot of other people out there doing myo these days who do not have the proper education or licensure to do that either. Fun times out there. And they all will say, oh, myo is the wild, wild west and it's not regulated. Yes, it is. Just because somebody decided to hop on the internet and say it's not regulated and everybody else agreed. It is regulated. It's regulated by our state licensure that we all got after going through graduate schools. And I know the OTs as well, we had to go to undergrad and graduate school and take exams and doing— do lots of continuing education. It wasn't just like, oh, I want to work with this population, so let me go take a course and get certified because this person certifies me. No. No. Who's— understand what certifications allow anybody and everybody to get certified because it's inappropriate. It's dangerous, it's unethical. If a provider is not qualified, they should be referring out. That is what a good provider does. All right, so one of the most common reasons that we actually see these oral habits like thumb sucking, for example, the reason why we see it develop is to fill a void. When the tongue is not resting up on the palate where it belongs, children often substitute with a thumb, a finger, or a pacifier. Okay, and I'm looking for one of my tongue models to show you guys. If that tongue is not resting up on the palate where it belongs, children will substitute with their thumb or a pacifier, and that habit provides sensory input, right? Stability to the jaw and the oral structures, and sometimes it actually even improves the airflow. Wild. This ties directly to feeding development, speech development, jaw growth and development, sleep quality, okay? And because in many young children who suck their thumb, that thumb is acting like a mandibular advancement device, right? When the thumb sits in the mouth, I'm gonna show you again if you're watching, it gently brings the lower jaw forward a little bit, even just a few millimeters. That small shift can open our airway and make breathing easier during sleep, okay? So the habit isn't random, it's compensatory. And if the airway is restricted due to the jaw position, our high palate, maybe enlarged tonsils or adenoids, maybe poor poor tongue posture, the posture of the tongue is low, maybe forward, right? The body finds a workaround. Our body's very smart. And that workaround, my friends, often becomes an oral habit. I wanna dive into what I mean by that because we have so many parents who ask us about like, what about bitter nail polish or sprays? What about a thumb brace or splint? What about taping the thumb? What about sleep sacks or restraints? These approaches may temporarily block access to the habit, but they don't address the underlying cause. And in some cases, they actually create new problems, especially when they restrict the movement or the sensory input. Okay, if the body still needs to fill the void, it will simply find another way. So what does work? Well, instead of asking, how do we stop thumb sucking? What we need to be asking is, what is this habit compensating for? Let me say that again. The question is not, how do we stop sucking the thumb? How do I get my kid to stop? It's, what is the habit that they're compensating for? Like, or what is— why is this habit compensating? What is it compensating for, right? What is this habit compensating for? And this is why this conversation matters so much. So I want to start with one of the biggest, most overlooked signs of airway dysfunction. And that, my friends, is audible breathing. Breathing should be quiet. If someone is truly nasal breathing with an unobstructed airway, meaning there is no obstruction, breathing is typically silent, whether you're awake or you're asleep. If you can hear somebody breathe through their mouth or their nose, something is usually off. So that right there is a tell-all sign, right? And here's something else fascinating. When someone transitions from mouth breathing, snoring, or loud breathing to quiet nasal breathing, especially in kids, like the parents or partners, they panic. And they're like, I kept checking to make sure they were still breathing because I couldn't hear them anymore. Like they're not used to that. That tells us how normalized dysfunction has become. And it's a little bit scary, right? If you hear snoring, loud breathing, gasping for air, mouth open, you know, you see mouth open sleep, you see restless sleep, we have to consider sleep disorder breathing. And this is true for adults and children. Okay? This might include snoring, UARS, which is what I was diagnosed with because I had sleep studies and I did not get diagnosed with sleep apnea. I got diagnosed with upper airway resistance syndrome, or UARS. Maybe you do get diagnosed with mild sleep apnea or obstructive sleep apnea. But let me say this clearly again: snoring is not normal. It never has been, it never will be. Unfortunately, it's been normalized in culture, but physiologically it usually means airway resistance. Okay? And no, my child sleeps 12 hours and never wakes up all night. tells you absolutely nothing about sleep quality. The question is whether the brain and the body are getting restorative sleep or whether the nervous system is being repeatedly pushed into fight or flight all night long, right? And so thus they might be asleep for 12 hours, but it's not restorative and their body is completely wrecked when they wake up. So this is where my story connects to so many families that a lot of us see now, right? That I see, that I'm sure you all see. There are kids and adults walking around with brain fog, with fatigue, irritability, difficulty focusing, hyperactivity, poor productivity, not feeling rested ever, right? And the default response is often ADHD diagnosis and medication. And I want to be very clear, ADHD is real, like it exists, and many incredible creative people have it. That's why I joke, but I'm also very serious, that it is my superpower. Without my ADHD, I'm like, I don't know that I would be where I am today because it allows me to really have a lot of creative thoughts and ideas and juggle a whole lot of things at the same time. Whether I'm doing it well is a whole different conversation, but here we are, right? Before we medicate though, especially in children and especially in young children, we must rule out sleep disorder breathing because a chronically sleep deprived or under-oxygenated— I know I couldn't say that. Brain can look like ADHD, can look exactly like ADHD, but it doesn't mean the child has ADHD. They might just be sleep deprived with an underoxygenated brain. So if no one looks at the airway, at the tongue, at the palate, the breathing, the sleep, right? We risk treating symptoms instead of causes. There is research that shows, and this is not to scare you parents and providers, but it— we need to be aware of this, right? There's research that shows that children with obstructive sleep apnea can score 10 to 16 IQ points lower than their peers without sleep disordered breathing. Yet many children who are diagnosed with ADHD or behavioral concerns have never had a sleep evaluation or an oral airway assessment. So what does work? Well, instead of asking, how do we stop thumb sucking? What we need to be asking is, what is this habit compensating for? Let me say that again. The question is not how do we stop sucking the thumb, how do I get my kid to stop? It's what is the habit that they're compensating for? Like, or what is, why is this habit compensating and what is it compensating for, right? What is this habit compensating for? Airway, oral rest posture, feeding mechanics, tongue function. The habit often resolves on its own. Wild, right? The tongue is meant to rest up on the palate. Here's my little mouth model again. We want it up on the palate, okay? Mm-hmm. When it does that, it releases calming endorphins. It supports the jaw and the palate development. It makes that nice, beautiful U-shape that's flatter and not like high and narrow and not super V-shaped, you know, or really narrow like I was saying. It helps stabilize our breathing, supports the upper airway. It eliminates the need for substitution. The oral habits are not random. They are signals. It's like throwing an SOS sign up, right? When we listen to what that habit is telling us and we treat the underlying cause, that root cause, we can support healthier growth, better sleep, improved feeding, and stronger overall development. We are quite literally connected from the tip of our tongue to the tip of our toes. Nothing happens in isolation in the body. That's my big PSA for today. If you're unsure where to go next, where to turn, you can reach me @halliebulkin on Instagram or visit pediatricfeedingtherapist.com to find vetted SLPs and OTs trained in pediatric feeding. You can also go to feedthepeds.com and hop on the waitlist so you know when we reopen the course. But thank you so much for being here. I'm done with my soapbox for today. I'll see you guys next time. 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. That wraps up today's special compilation. My goal with these episodes is to bring together the conversations and the insights that are truly moving the needle in our field right now. Next, whether you're a parent looking for answers or a clinician looking to sharpen your skills, remember that the most important tool you have is your own clinical reasoning. Don't just look at the surface level symptoms. Look at the underlying systems. If today's episode shifted your perspective or gave you a new aha moment, I would love to hear about it. Take a screenshot of you listening, post it to your stories, and tag me @HallieBulkin. You can always find more resources and past episodes over at untetheredpodcast.com. Thanks for tuning in, and I'll see you back here next week. Next week on the Untethered podcast.