When You Screen a Child and Think 'Now What?

Red flags, my friends, they are not the whole plan. They're the doorway to the right next step. Step 1 is screening. Identify the red flags and determine the risk. Step 2, assessment. Determine underlying drivers. Step 3, treatment. That's where we prioritize and we intervene. 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. Let's talk about a moment almost every feeding therapist has experienced, okay? You're screening a child, you go through your questions, you observe the meal or the snack they're having, and you notice several red flags. Maybe it's limited variety, gagging, pocketing. Maybe there's avoidance or long, you know, you're not gonna see a whole meal, but like the snack takes a long time to eat. History of reflux. Maybe there's some mouth breathing, right? And you finish and you think, okay, something's off. And then there's this pause, and it's like, now what? Is this picky eating? Is this a feeding disorder? Does this warrant assessment? Do I monitor? Do I refer? Do I start treatment? If that moment feels familiar, I want you to hear this clearly: this is extremely common, especially early in feeding practice. And here's the key distinction that will reduce a lot of confusion. Red flags are not a treatment plan. They are a decision point. Red flags tell you whether you need to look deeper. They don't tell you how to treat, and that's exactly how they're supposed to work, okay? So I want to talk for a moment, like, before we go any further, I want to be very clear: screening is not optional, right? It's important. It's super important. Screening protects kids, it protects families, it protects clinicians. Without a structured screening process, two things tend to happen, okay? We either miss children who genuinely need help, or we over-pathologize normal developmental variation, and neither is ideal, right? So a structured feeding screening checklist helps you answer one very specific question. It makes it super clear. Is this within typical limits, or is further assessment warranted? That's it. Screening is not diagnosis. It's not treatment planning. It's not solving everything. It's determining risk and next steps, and that alone is super powerful. Okay, so here's the thing though, right? I see confusion creep in because many clinicians think like, if I can identify red flags, I should automatically know what to do next. But that totally skips a step, right? Screening just answers like, should we assess further? An assessment is what answers why is this happening, what system is driving it, is treatment warranted, what do we prioritize? And so if you try to jump from screening straight into treatment decisions, you're gonna feel unsure because you're missing some critical information. And that's not a competence issue, that's a sequencing issue. So let's talk about a few very common screening mistakes that I see, especially with clinicians who are newer to feeding. And this is not like to put anybody down. It's not because they don't care, right? It's because nobody explicitly taught them what a screening is and isn't. So, okay, here's the first mistake that I see happening: treating parent concern as the only data point. Confidence in feeding therapy starts with screening. If you're an SLP, OT, or PT who wants clarity before diving into feeding cases, join my free 3-day training, Screen the Peeds to Feed the Peeds. Sign up at feedthepete.com/training. Sometimes a parent will say like, he's picky, or she just doesn't like certain textures, and we either dismiss it too quickly or we escalate it too quickly. Parent concern absolutely matters. In fact, it's super critical to be listening to what the parents' concerns are and why they're there in the first place, right? But screening requires structured observation and targeted questions. Without structure, we risk under-identifying like those true red flags or pathologizing something that is developmentally typical, and a check Checklist ultimately gives you objectivity. It helps you move from opinion to data. And I mean, when I say this and I share this with you all, I'm not just talking about in private practice or in a school system or, uh, in an outpatient clinic. Like this is happening in hospitals. This is happening in, in every single setting where either we are under-identifying the true red flags or we are pathologizing something that is actually typical development. Wild, right? So mistake number 1, treating the parent concern as the only data point. I shared why that's That's a mistake. Important information, but not the only data point. Now, mistake number 2: equating limited variety with sensory. It's just like automatically doing that. Okay? We don't want to assume that limited variety automatically means there's a sensory issue. This one is huge. Limited diet does not automatically equal a sensory disorder. It could reflect maybe delayed oral motor skills or fatigue or airway instability. Maybe there's GI discomfort. Rigid routines could be present. Maybe they have learned avoidance, right? If we assume sensory too early, we may miss motor or medical factors that warrant further assessment. Okay. The screening should be there to widen your lens, not narrow it prematurely. Okay. And then mistake number 3 is skipping the safety layer. Please don't do this. This one matters the most. Sometimes clinicians focus heavily on variety and exposure and they miss things like the child coughing with liquids or a wet vocal quality or frequent respiratory illnesses. Maybe they have mouth breathing or chronic congestion or history of choking. Like, those aren't feeding quirks, my friends. Like, those are safety and airway considerations. And a structured screening checklist forces you to scan for this. You're scanning for these risks. Like, it's not just a preference, right? That is going to protect you and it's going to protect the kids. And none of these mistakes are happening— I just want to clarify this— they're not happening because clinicians don't care. They're happening because screening without structure relies too heavily on memory and instinct, right? Human bias, like, things kick in. That's what we need, these structured tools. Instinct alone is not enough in feeding. So what a good screening checklist actually does, right, a strong feeding screening checklist helps you identify risk factors, spot symptom clusters. Maybe you can notice if there's some developmental mismatches, right? Maybe you're flagging medical history concerns. Maybe you're recognizing airway and safety issues. Issues. You may determine whether a comprehensive feeding assessment is warranted. Ding, ding, ding! That is the biggest one that we're hoping comes out of this, right? That is ultimately the goal. We want it to give us clarity about the next step, not the whole journey, just the next step. So instead of thinking like, well, what do I do with all of this? You think, ah, based on this screening, further assessment is warranted. That's clean, that's ethical, that's professional. It's clear, right? So I want to simplify the sequence for you into 3 steps, okay? Step 1 is screening. Identify the red flags and determine the risk. Step 2, assessment. Determine underlying drivers. Step 3, treatment. That's where we prioritize and we intervene, right? When clinicians skip step 2 and jump straight from the red flags to treatment, they feel overwhelmed. Do you know why? They're not following the sequence. But when you follow that flow of that sequence, right, confidence increases because you're no longer guessing. You're moving systematically. So I wanna give you an example. Let's say during screening you identify limited diet. There's frequent gagging, history of reflux, mouth breathing, long meal times, right? The screening checklist ultimately helps you determine this is not simple picky eating. This warrants a comprehensive feeding assessment. Again, that's clarity. The screening just did its job. Then during assessment, you determine, okay, is this primarily motor or physiological, or is it airway related or behavioral, or is it multifactorial, right? That deeper interpretation happens in assessment, but you don't get there without a structured screening first, unless someone comes to you and says, we have concerns, Family's ready for assessment and you can go straight to assessment. You don't have to say, oh, pause, let's do a screening first. No, we've already determined assessment is warranted in that case. It's fine to proceed with assessment. This is for when you're starting with a screener or if you're not sure if a kid needs to be assessed or not, that's when a screener would be most appropriate. Okay, here's the thing. Confidence in feeding therapy does not start with treatment mastery. I know everyone thinks it's treatment mastery, give me more strategies, I need more tools in my toolbox, right? It actually starts— that confidence starts with clean decision-making, and clean decision-making starts with structured screening. When you know this meets criteria for further evaluation, you feel steadier because you're not relying on gut instinct alone anymore, right? You're relying on a systematic process. Good screening doesn't make you alarmist either. It makes you intentional. So this is why I created the Pediatric Feeding Screening Checklist and Packet, basically, because it walks you through like what to look for, what patterns matter, What differentiates typical from not, you know, well, I'm concerned, right? And when further assessment is indicated. It's not a treatment guide. It's a clarity tool. And it helps you move from, mm, I think something's going on here. I think something's off to yes, this warrants a deeper look. And that shift alone can change how confident you feel in early feeding cases. So if feeding sometimes feels overwhelming, it's often not because you don't care enough. It's because you're trying to skip steps. And screening creates clarity about risk. Assessment creates clarity about the cause, and treatment creates change. Red flags, my friends, they're not the whole plan. They're the doorway to the right next step, right? And when you understand that sequence, feeding feels less chaotic. It feels more structured, more grounded, and red flags are just— they're the beginning of clarity, not the end of it. So I would love to invite you to join me on my free 3-day training on how to screen your first pediatric feeding patient using my screening checklist. Go to feedthepeds.com/training and join me. You're gonna get 4 hours on a certificate of completion and so much more. It's coming up. So make sure you enroll again, totally free. And I cannot wait to see you in there. 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 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 @halliebulkin on Instagram to get all the latest updates.