In this episode of the Untethered Podcast, host Hallie Bulkin and a panel of clinicians discuss the challenges faced by newly‑graduated speech‑language pathologists, occupational therapists, and physical therapists when entering pediatric feeding and dysphagia practice. The conversation opens with Hallie's own experience of graduating during the pandemic and discovering that most dysphagia coursework is adult‑focused, leaving a knowledge gap in pediatrics. Panelists share their career paths—from private practice to community hospitals—and describe how they gradually built competence through hands‑on work with bottle‑feeding, lactation, and early‑intervention cases. A major theme is the misconception that a single course can make a therapist “competent” in pediatric feeding; many clinicians feel unprepared despite extensive coursework. The group emphasizes the importance of mentorship, deliberate practice, and critical thinking over protocol‑driven treatment. Tongue‑tie assessment emerges as a concrete clinical topic. Speakers describe how they identify functional limitations, the variability in scope of practice across states, and the need to collaborate with dentists, ENT surgeons, or oral maxillofacial specialists for releases. They caution against over‑reliance on visual assessment alone and discuss downstream consequences of untreated oral restrictions (e.g., TMJ dysfunction, sleep apnea). Interdisciplinary collaboration is highlighted as essential for complex cases, with clinicians noting the value of consulting PTs, OTs, physicians, and school therapists. The episode closes with encouragement for new grads to invest in themselves, adopt a growth mindset, seek supportive teams, and recognize that confidence stems from competence built through mentorship and experience.
Chapters
All the dysphagia I got was mostly adult geared. I had maybe 2 lectures that were for pediatric dysphagia and I was like, wait, I want more.
Certainly most people get better with that, but I just started to recognize that there was a certain percentage of my patients that weren't responding well to a traditional orthopedic process.
I'm like, look, like at the end of the day, none of us know everything. Like I don't know everything. People who have been teaching for 50 years, who have been in the field for 60 years, like they don't know everything. I don't think I had any. I had zero, like no peds dysphagia at all. And it was so interesting because I feel like it was a program where we got such a great view on like peds and adults throughout most other areas. So the fact that like the dysphagia courses were so heavily focused on adults with like no recognition of pediatrics was very fascinating. And I was kind of like, I like this, But I don't want to work with adults, so we are moving on. Yeah, exactly. Yeah, so, so tell us, so you came out of school, obviously the world shut down, the pandemic started, you jumped into the course, like what's happened since then?
So since then I worked at a private practice where we served a lot of little ones with pediatric feeding disorders. I kind of got my feet wet there. With some of the school-age kiddos and kind of backed into the younger kids and did a lot of observations with lactation and some bottle feeding. And then I had the opportunity to work in a community-based hospital setting, which is where I am now. And I do a lot of early intervention and a lot more bottle feeding, a little bit of lactation, a lot of transitional feeders come to see us. So it's been crazy.
A lot of SLPs and OTs think that if they just had another course or the right course, they could treat feeding patients. Spoiler alert, this is why so many therapists take the courses and continue to dream of being competent pediatric feeding therapists. A lot of people walk away and they can't call themselves that. I can't tell you how many SLPs and OTs I've talked to who have taken endless courses and still don't feel comfortable even calling themselves a pediatric feeding therapist. I'm not talking about a specialist. I'm just talking about someone who does pediatric feeding, therapist. That's it, right?
I took a very traditional route of doing a sports residency, which maybe isn't the best way to say traditional, but traditional orthopedics of let's check range of motion and strength. And if something doesn't move well, let's stretch it. And if something's not strong, let's strengthen it. And certainly most people get better with that, but I just started to recognize that There was a certain percentage of my patients that weren't responding well to a traditional orthopedic process. And so I was fortunate in my 3rd year of PT school to get introduced to Postural Restoration Institute through my clinical instructor, which I jokingly say is a blessing and a curse at the same time, because once you learn a different way of thinking, you can never unsee it, right? I think that's probably been your experience in treating patients. And so I just wasn't able to have a traditional look at how somebody moves. And so just able to see patterns of things and recognizing that it was beyond just bone and muscle and ligaments, and that there is other systems that are involved in how we move. And so ever since then, I've been on this 13-year journey now of trying to figure out how can I best Like, at one point I was really into working with like children on the spectrum.
They were just— I loved like the challenge and getting, you know, figuring out their best ways of communicating. But then I started to notice like their eating patterns and their stomach troubles, like constipation. And then, you know, and I was like, okay, this is interesting. And that like threw me down another rabbit hole. And then I had my first child and I fell down the Tots and Miles rabbit hole. And here we are. Here we are. So do you find like, are you doing tongue-tie assessments? Do you find like a lot of mouth-breathing babies, or are you doing, you know, are you seeing different things where you are?
So it comes in waves. There's like months at a time where we get a lot of tongue-tie assessments, and then, but I mean, throughout my practice when I'm even just evaluating kiddos for language or speech sounds, I notice all of that and I definitely incorporate what we learned in the course. And through courses that I've taken after into my practice and just help explain things to parents in a different way.
I was like, okay, sure. And my— that day I felt like I got hit by a car when I met her back then and the way she described the function of the tongue, the way it impacts the airway, the way it can block the airway, how it can be dysfunctional and how it impacts sleep and my— and how I knew sleep impacted like sensory processing and attention and all these higher executive issues that we work with with kids, I was like, oh my God. I was so, I was so in shock that day. And I personally also have my own myo issues. I had ear infections my entire life until I was like 30 and I had a really, a really bad one. And I've, I'm currently, I have 2 ALFs in my mouth. Like I'm, I've been on the other side of it too. And so when I learned this stuff, I went back to my clinic and I was opening every kid's mouth and like 40% of them had big tonsils. And I was like, oh my gosh, how did I, How do I not know?
We can't just take a picture and go, oh my gosh, that kid is so tongue-tied. Now, when you do this for a while, you can look at a tongue and be like, oh wow, like that's a heart-shaped tongue. Like that tongue is really just stuck to the floor of the mouth. They can't elevate it at all. The sides barely elevate. The tip is completely pinned to the floor of the mouth and go, hmm, I wonder like how this, this person, if it impacts their speech, if it impacts their sleep, if it impacts, you know, their, because of their ability to breathe, if it impacts their ability to chew and swallow their food. And so Most likely, yes. Now, yes, because obviously they can't do what they typically would need to do, which is elevate that tongue for a lot of these activities. And they just can't possibly do that if it's physically tethered to the floor and it can't elevate at all. Some people learn to compensate and some people compensate very, very well. And so it also just comes down to, do you want to live a life of compensation where it can snowball over time and potentially lead to other issues like we see Temporomandibular joint dysfunction. We see migraines, we see obstructive sleep apnea, we see a lot of things snowball into adulthood that greatly impacts our overall health. Can we say that every tongue tie is going to do that? No, we can never say anything definitively, but can we say that we see a lot of adults who have tongue ties— obviously it was there at birth— who have developed into adults with these issues? Yeah, we see that every day in our practice. So So again, it comes down to not just how it looks, but how is it impacting function? This is not in the scope of an SLP, a speech-language pathologist, an occupational therapist, a registered dental hygienist, right? This is typically only in the scope in terms of determining if a release is needed and the details regarding the release is in scope for the release provider, which is typically a dentist, an orofacial maxillary surgeon, an ENT, right? So those providers typically determine whether or not a release is needed, but depending on where you're located, you may be able to diagnose a tongue tie or a lip tie or buckle ties, okay, cheek ties. So know where you live, know what the rules are where you live. You know, for example, where I exist, where I'm licensed currently, like in Maryland and Florida, for example, I can diagnose. I have a specialized level of training. Not everybody does, so it really depends again on where you live, what your specialty training is, and so on and so forth as to one, whether or not you can diagnose, and then, you know, who is the available provider in your area to determine if a release is needed. How do we determine, right, who we need to send for a release consult and who we don't think needs a release consult? Because again, as an SLP, I, even though I'm certified in orofacial myology, I cannot say yes, this patient needs a release. No, this patient doesn't. Now, do we have conversations behind the scenes with some of our release providers who say, hey, like, what do you think? And I'm like, hey, this is your scope. What I can share though is, you know what, I think it's impacting function. And I think that if we did have it, it would, you know, we'd be able to do X, Y, and Z in therapy and they would greatly benefit from that release, right? So I'm not saying yes, they need the release, but I'm saying this is what I feel is happening as a result of that tethered oral tissue. And this is what I think may, may happen if we don't have that restriction in place, right?
It's okay to be scared. It's okay to be nervous. If you're not nervous, then there's an issue, you know? Taking the time to find a supportive team and find a mentor like you have in Feed the Peas To use as a resource and to talk about cases and evals before they come, to have a good plan so that you feel confident. And growing your skill set that way, I think, is a really good place to start because, like you tell your patients, you need practice. If you don't have practice, you're not gonna get better or grow, you're just gonna stay stagnant in the same place. So you need to do the same things and Pushing yourself is hard, but you feel so much better afterwards.
Confidence comes from competence. So developing your skill set is vital to becoming the person who treats instead of the person who dreams of treating while writing another referral. You hear me? You hear what I'm saying here? And mentorship also is critical during your journey because you gain the feedback that you need to know that you're applying your knowledge correctly, right? Guidance and mentorship are catalysts for change. Have you fully considered that referring patients to these like far away specialists in big cities with waitlists is increasing the anxiety that families feel about their child's condition? Like even a local referral honestly could be causing a family anxiety. If they come to you, they trust you. And if this is a skill set you desire to have, I want that for you just as bad as you want it for yourself, right?
Invest in yourself. You're worth it. You're worth the time. You're worth the money. You can do lots of things if you persevere and you push through and you have a growth mindset and know that you're not always gonna have the answer. It's okay not to know. It's okay to ask questions. It's okay to be vulnerable because that's how you better yourself for not only your own clinical practice but your patients and serving whatever Yeah, again, I love this, like the whole growth mindset thing, you know, it's like growth over comfort, right?
Like you can either stay comfortable or you can grow. It's like I can give you a whole library of exercises, but that doesn't actually totally tell you how to do therapy. Like you need to know what you're doing, why you're doing it, what you're working on, what the end goal is, and like how are you trying to accomplish that?
Yeah, I And think that's a really good point.
I think you touched on that earlier too, but that was like one of our big goals. It was like, I feel like I left all these courses and I was kind of like, I don't know what to do. Like, I have some ideas for a couple patients, but like after that, then what? And I also think that was my mindset, like coming out of school was kind of like, well, just tell me what to do and I'll go do it.
Mm-hmm.
And you know, so like, it's— I don't blame any therapist who comes and asks for that, but then I'm kind I'm kind of like, pump the brakes, like let's have a conversation. Critical thinking, like we seem to have lost like this whole, like even me, I was like, we seem to have lost the ability to be critical thinkers, like analyze what's in front of us and create a treatment plan based on the patient, not like a protocol.
When you get those complex kiddos too, that's where I'll go and collaborate with my PTs and my OTs and other physicians. And school therapists and other people that they're seeing so that it's a really comprehensive treatment too.
Yeah, and that's, that's so important. I mean, it's like if I haven't drilled that into everybody's heads, like either through the course or my podcast or whatever, I'm like, teamwork, collaboration.
I tried to ask questions where I felt like I couldn't Google the answer, and it came through experience. Or mentorship, and just be curious and always learn and always push yourself to grow because we're never done learning and you're never done growing.
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 on the Untethered Podcast.
