Functional Oral Motor Examination

Welcome back to the feeding pod. This is Bree and today's episode is a good one. I am accompanied by Dr. Catherine Sanchez and we are discussing the oral motor assessment. Now, it's not what you think. We're not just gonna be going over how to complete an oral neck exam, but we are deep diving into the importance of a functional oral motor assessment and what that really means. We're gonna talk about the key factors to look for in an oral motor assessment. We're gonna talk about tips in completing an oral motor assessment in pediatrics because after all, we all know how difficult it can be to get in a child's mouth during an evaluation. On top of that, we're gonna talk about the importance of assessing oral motor skills and a contextualized manner versus decontextualized. We're gonna talk about what should be considered for a functional oral motor exam and why that is important. This episode's really important to me because I'm a firm believer in looking at the targeted skills we're trying to achieve in the most functional manner we can. We have to look at what the child is doing in the context of the targeted skill if we really hope to gain insight on what they are capable of. So, without me giving away all the information on today's episode, let's go ahead and dive right in and get started. (upbeat music) Welcome to the feeding pod. I'm Bray, your co-host. I am a speech language pathologist and certified lactation counselor. I work with infants and medically complex patients with PFDs in the home and outpatient settings. I enjoy building relationships with families and I'm a firm believer in providing interdisciplinary care. I also love providing mentorship and support to upcoming and new clinicians on pediatric feeding disorders. You can find more about me on my Instagram at Pediatric Feeding SLP or on my website, pediatricslplibrary.com. And I'm Olivia, co-host, registered dietitian nutritionist and certified lactation counselor. I work in a pediatric clinic where I get to divide my time between working as a CLC and an RDN for infants and children. I enjoy being able to help caregivers navigate through these difficult times that include the newborn faces all the way through the teenage years. I feel that my personal experience from having a newborn who's now a toddler and the child with special needs, including a feeding disorder really come into play. We are here to bring you multidisciplinary evidence-based information that is easily accessible about pediatric feeding and swallowing disorders. We understand firsthand the importance of collaboration and how difficult it can be to navigate the ever-changing information on assessment and treatment of pediatric feeding disorders. The feeding pod is here to provide research, support, and a dash of calvac relief. Now, let's dive right in. Disclaimer, all statements and opinions expressed in this episode do not reflect on the organizations associated with the speakers and are their own opinions solely. This is intended to be educational in nature and does not replace the consultation, diagnosis, and/or medical treatment from a qualified health care provider. I'm Brie and today I am accompanied by Dr. Catherine Sanchez. And if you haven't listened to our episode from season one on tongue ties, highly recommend go take a listen. But today we're actually going to be talking about completing a functional oral mac exam. So we're thinking about oral motor skills with pediatric. We all know this can be a little bit tough to approach with some of our little ones. So before we start and dive into this, though, Dr. Sanchez, why don't you give a quick introduction? Hmm. So I did my PhD a few years ago on our motor function in children born before 30 weeks of gestational age, looking at feeding and speech. And that was sort of how I really got into doing a lot of oral motor exams and a lot of oral function exams. So I'm super excited to talk about this topic. In addition to sort of that academic string to my bow, I am a private practice owner. I see mostly medically or developmentally complex children zero to six. And I'm also the pediatric medical editor for the informed SLP. Awesome. Well, yeah, this is obviously one of those are obviously one of the reasons I brought you in was because you have studied oral motor skills in pediatrics so extensively. And so I think you just can shed a lot of light on what we, what we as clinicians think about when we're performing these oral motor exams, what we need to look for. And yeah, I'm really excited to get started with it. So kind of starting out, what are some of the first things we should think about when we are completing an oral motor exam? So I think I mean the oral motor exam starts the second you see the child really because you go straight away, you're looking at some of their facial features and facial structures looking for symmetry, doing some of that real basic sort of examination and looking at oral behaviors outside of an examination context. So if they're sucking on a dummy or chewing on their fingers or if you go out and they're chewing on crackers and they're spread all over the waiting room, then you can get quite a lot of information before you even start the formal part of your assessment. And I think yeah, we need to think about it as starting really from the seconds that we see the child. I do try and get into a child's mouth. I often do it at the end of the session, just in case that is like it. So do all the fun stuff first and then do the exam with the inside of their mouth after that. And looking at the tongue, looking at tape, looking at palate and veal function. And then I think it's, I think we've talked a lot about how we always wanna look at how a child is speaking and eating and drinking as well because those are the functions of the oral mechanism. And that's what I think what we're gonna dive into a bit more today. - Yes, yeah, definitely. I think two you made a good point of like getting into the child's mouth at the end of the session because a lot of children that are coming to us, if they are having difficulties with feeding, a lot of times they're very aversive. So if the first thing we do is, you know, walk over, try to get into their mouth, that's gonna just, the whole rest of the evaluation is gonna be tough. It's gonna be hard to build that report. And I honestly can say that I have had some kids that it is not gonna happen and I'm not gonna push it and we'll figure it out later. And that's why I think talking about this oral motor exam and a functional manner is important as well because there's so much information you can obtain about a child's skills from those observations from the start, from eating, drinking and talking right away. - Absolutely. And I think, you know, I definitely think that there are kids where I don't get into their mouths in the first session because they're just too resistant and I think the therapeutic relationship is more important than getting a look in their mouth on the very first session. I will then just make a note. In my clinical notes that I need to get a look in their mouths, you know, in the second session or the third session. And the other thing is, is making sure that you're being opportunistic. So if they're having a big belly laugh or, you know, if they start crying, then that might be your opportunity to have a really good look in their mouths without having to sort of do a purposeful task where you, you know, have to try and prize their mouth open. - Yes, no, I completely agree. I think, you know, like you mentioned with being opportunistic, like if you can get them giggling or playing with a toy and then you're also just ready to take that quick peek and then you bring them back up. You know, I'll have parents kind of do, I think it's like called like the guppy where they like lean them, you know, a child leans way far back and you're like, oh, but you can do like peekaboo. You can do, you know, especially with our little, little kids who just maybe aren't sure what's going on. There's a lot of ways you can take over with that. What are some other tips that you might include if you're trying to get that look in the child's mouth? - It definitely depends on the age of the child. I think I think those, some of those opportunistic sort of methods and, you know, getting the child leaning back on their parents' life work really well for little kids, little infants. For the older children, it's not always quite so easy. So I think mirrors can be really helpful. If you've got a nice big mirror that you can sit in front of together, I think, you know, that can be really fun and then you can just, you know, we're doing Croft and Al mouths or we're doing a big roar like a lion. And oh, my goodness, I can see your tag and see all the way back into your mouth and, you know, and make it sort of fun like that. I saw a wonderful post on Instagram about using phone filters or a motor exams going. So getting your phone or your iPad out and using some of the filters that like change the way a child's mouth looks. And then you're actually doing the examination by other, you can either do it. - I'm sure, yeah, I'm sure a lot of older children really like to do that. - Yeah, you sort of like three, four-year-old. - Yeah. - And I think that's super fun and just makes it a little bit less clinical and a little bit more sort of gamified because they can, yeah, they can make the mouth do all different things. And suddenly all of your oral meditats are just fun things that they're doing. for that fun feedback. I think picture cues can be helpful as well. So I sometimes use the ones from Adventures in Speech Pathology, which has just got a picture of a child blowing out some candles or a picture of a crocodile opening its mouth really wide. And then you can use some of that, talk about that imagery as well, so that you're not asking a child to stretch their lips out. You're asking them to give you a big smile. And you're not asking them to purse their lips, you're asking them to blow a kiss to mum, so that it's stuff that is a bit more relatable in terms of what they would be doing in their day to day activities. Do you have any extras? Because I always came for extra tips on how to do. Oh, no, I think all of those are really great. A lot of times I will, I think probably because I mostly see under three. I'm doing a lot of like playful games, a lot of just playing. I notice kids love the mirror, love looking in the mirror and trying for that. A lot of times like you mentioned, it is something I'm doing at the end. So I usually am taking note of what I can during some of those more functional tasks and observations. And I'll usually cut down what I'm doing in that more structured manner based on what I'm already, what I've already been able to observe. And so that way I find that that helps as well, because I think a lot of times by the time I am hoping to look in their mouth, it's usually an assessment more of structure, you know, and actually how it's functioning. And I'm just making sure like what the, what do the structures look like, but a lot of times when I'm watching them eat or drink or speak is when I'm actually finding out how they're functioning. Yeah, I completely agree. I think eating and drinking is just you get so much good information from that part of the assessment. And my, I guess my most intensive experience doing all more to anything was scoring. And then I'm going to go over 200 somers, which is the schedule for, um, oral motor assessment, which is a standard as feeding assessment. And you give them a series of different textures. So puree, semi solids, solids, chewy foods, and then they drink from either a bottle or a cup or both. And you score them on different oral motor behaviors when you watch the video back of them taking those foods. And so yeah, I did several of those assessments and then I watched them all of the videos back all 220 something of them. And scored oral motor behaviors. And then I went back and did another 10% of those again for into for intra rate of reliability. And then it's really amazing how much information you can get just from watching a child eating him. I agree. But then there's always that case of like the child doesn't want to eat or drink in front of you. Because now, you know, when we think again about rapport, you have that kid that's like, I don't want to do anything. So, you know, for for me, sometimes I will one of the first things I'll try just to see if they will, I'll be like, I'll be right back. I'm going to go get a couple water or I'm going to go to the restroom or you know, I say something. And I kind of tell the parents like, go ahead and get started. And I'll leave you for a couple minutes. And hopefully when I come back, the child's a little more comfortable. They're having fun eating with, you know, their caregiver. Some observations while I still kind of acting like I'm not paying attention to them. And I'll usually try that first. But what's another strategy you might use of a child is like just not willing to eat at all. I look at a lot of videos on parents phones. And I think this is definitely increased in the last 18 months in where I'm from in Melbourne in Victoria. We've had quite a lot of lockdowns where we haven't been able to see children in person. Under most circumstances. So I get families to take and email me videos of their child's meal times at home. And so most parents have videos of their kids eating on their phone. So even if you haven't pre-prepared for, you know, for reviewing videos, I often find that if you say to the parents, have you got any videos of them having a feed or, you know, having something to eat. They can often bring something up and it might not be the most typical meal time because maybe it's one where they gave them a food and they found the way that the child dealt with the food really funny. And so that's why they took the video. And I think you can still get some really nice information from those sorts of parent videos. And I think they're a bit of an untapped source of gold for us. I agree. I agree. I love watching those videos. I think to sometimes it can tell us a little bit about the psychosocial side of meal times as well of like how did they respond if they're like, oh, this was a meal that was difficult in the child gag. I think what did the response look like as well to gain input on that. But I agree. I think the more opportunities that we can observe the more information you can gain about the child's or motor skills to really be able to say what's going on. So moving on as we're thinking about, okay, we understand oral mode exams. We all know that they are important. We all know it's really important to figure out what's going on with the child from the oral motor standpoint. What can they tolerate when we're thinking about a functional assessment of it. What what is this kind of moving toward because I think I always kind of differentiate between a moral motor exam and a functional oral motor exam. And, you know, I think ultimately we should be kind of doing that together like a functional oral motor exam really is an assessment of both. But sometimes I think when we first get out of school, we think about an oral met exam. Okay, smile, pucker, tongue out, put your tongue up, put your to, you know, and we think about all of those things and in pediatrics. It's really hard to get a child to follow those directions. So when we're thinking functional just kind of shed a little bit more light on that area. Yeah, I guess when you're often when you're doing an oral met exam, I feel like the purpose is about ruling things out, you know, you wanting to rule out a clutch palette or you wanting to rule out any sort of neurological issue that you may have previously been unaware of or you know, or rule out major issues with dentition. Whereas I feel like functional oral motor exams because we are functional therapists and we work on function. I feel like functional assessments are where we set our goals for therapy. That's what we notice where the child is struggling and and and where they need help and maybe even how we might be able to implement that help. And another thing I know this is a feeding podcast, but I think that dynamic inventories can be really helpful for some of these older kids as well because I think I'm going to share a case study a little bit later where the dynamic infantry was a really interesting part of the, the assessment. Because I think that they can give us some really nice information about lip and tongue function that can fit in in an interesting way with what we find find out about eating and drinking when we're looking at a child's eating and drinking. So yeah, I guess I guess for me that the functional end of the oral motor exam is is the bit that really helps to guide and shape the way that we would provide therapy for children and what we need to target for them. I think it's important to acknowledge as well that functional assessments, I mean, oral making assessments to some extent as well, but functional assessments with the data behind our norms for oral motor feeding is really poor. And I think a lot of people don't realize that these norms are not, you know, completely reliable or derived from a huge population of children and confirmed many times in many different contexts there. And I think that it derived from some quite small studies in some cases unpublished studies that were never peer reviewed, but those are just the best we've got at the moment. So I think we also, we also need to acknowledge that when we're looking at some of these oral mechanical functional exams. And that means that one of the best things that we can do to make out our examinations more reliable is to just watch a lot of kids eating and looking at its mouths. And I was literally just the other day was on a call and was like, have y'all ever just sat at a daycare and watched kids eat like just watch lunch time at a daycare. And, you know, you could be sitting there. None of the kids are, you know, have feeding issues like it's okay, but you just watch the meat and it is so interesting to get that picture of the range of normal. And a huge range of normal and I think that probably goes a little bit into why we don't have very comprehensive data on what is, you know, functional norms for oral motor skills because the range is huge. Yeah, absolutely. Yeah, and Terry is spillage everywhere when you're looking at a typical, you know, or chocolate, yeah. Oh yeah, and some of the kids are taking huge bites. Some of the kids are picking and doing little tiny bites, you know, like just looking at it as a whole, you're like, what is going on. And I was talking to someone recently who has seen a client that I see as well. And, and this child is eight months old, I think, and for various reasons started quite late on solid, got quite a complex background. has now started to. six of liquid as well. And this clinician said, oh, when she's taking an open cup, I noticed that she was coughing. So I'm just wondering if she needs a video fluro to look for aspiration. And I was like, look at a typical eight month old with an open cup and almost all of them, like, I was just not saying that we should watch the cup and look for whether it's consistent and look for when it happens and whether they can clear and all of those things. But yet, typically developing, you know, a six, eight, nine, ten month olds with an open cup will cough a lot. Yeah, that's, you know, if we even think from the oral phase, just trying to manage that, but like that is a completely new experience for them. And then also, if someone is pouring something into your mouth, so if the parents helping facilitate it, that makes it more difficult. And if the eight month old or, you know, child, this just has motor limitations is trying to independently drink from that open cup, that can provide a level of difficulty as well. Yeah, absolutely. And yeah, unless you go out and watch a whole bunch of typically children, developing children eating, you don't realize maybe that that is happening. And you think, you know, think back to your adult placements and where bedside puffs were just, you know, like, oh, turning on those, that radar for looking, you know, looking for daynights. So yeah, I think sometimes just watching, as you say, sitting in a daycare and watching a kid eat, or, you know, you play, you kids play a group or in this as a nephew or whoever, can be just really powerful for figuring out what looks normal. Yeah, normal. I know. Because it's a big range. It's a very big rent. You'll see one three year old eating and then another three year old. And it could look totally different, but, you know, kind of going back to that functional side. So like, what what is the purpose and why you are assessing their oral motor skills? And what can you then obtain from that information for creating goals? Absolutely. And in terms of judging that those behaviors and their functional, I think in terms of effectiveness, efficiency and acceptability. I think those three really key things to think about. So if their oral motor behavior is effective i.e., they can effectively, you know, chew up the textures they need to chew up. If they can also do it efficiently, do it in a decent amount of time without losing too much. And if it's acceptable, so, you know, obviously for older children what's acceptable among their peers is going to be different to these younger children what's acceptable. And then I think it's functional. And, you know, and compensatory on atypical or non-typical behaviors can be efficient, effective and acceptable just because it's not the way that we think they should do it doesn't mean it necessarily needs to become a target for therapy. I think you touched on this in your in your first season in one of your episodes about about function and oral motor behaviors. And I just thought that that was a wonderful episode because it really, it really talked about how we don't need children's eating to be perfect as if there even were a quantifiable possibility of perfect eating. But we need it to be effective efficient and acceptable. And that's what we need to work towards. And yeah, I think a good example of this is tongue thrust. And tongue thrust following a lot of people if they see a tongue thrust follow will get really concerned. But we have some studies that show that, you know, 40 to 50 percent of children have a tongue thrust follow. And if it's a tongue thrust follow that is not interfering with function, then is it something that we as speech pathologist need to work on? I think it's something that we should, yeah, a question that is good to have to ourselves. Yeah, definitely. And I think, you know, like you said, thinking about the effectiveness, the efficiency and the acceptability is important because when we are providing these oral motor assessments, again, the normative data is very limited. But on top of that, if we're just going off of our clinical experience and opinions, it's at a high risk for bias. So when we don't have that research to back up, these claims were making about how a child should function. It's at a very high risk of bias of what we feel is functional. And so I think we have to be really careful about that and really think of that the whole picture and, you know, thinking about the tongue thrust as well. Okay, well, let's think of those criteria. And is this something that right now, us as speech pathologist need to be addressing, or does that bridge over into another professional who may or may not be taking taking over on that? Absolutely. And, you know, and I'm certainly saying kids wear a tongue thrust follow pattern has not been functional. So I think a three year old, I saw who had a brain mouthamation and she had this really strong tongue thrust swallow that was pushing about three quarters of every ball of sat up her mouth, every swallow. So it was really affecting her effectiveness and efficiency. And so we did work on that tongue thrust swallow because it was a real functional issue for her eating and drinking. And luckily, she was a little one where the side wear spoon technique worked. And that's the love on that track works. So, you know, so we got to the point where she wasn't wasn't extremely much of the ballless. And I was working in an acute setting and a consultative setting where I wasn't able to follow her up therapeutically a lot, but, but, you know, just in sort of two sections, we managed to get that down to a quarter. So hopefully she continued to improve. But yeah, I think that's an example of a behavior that can be ineffective inefficient. Then you'll get some kids who have a tongue thrust swallow and they're consuming all of their calories early. And they are closing their mouth when they swallow and there's no acceptability issues and it's working perfectly well for them. And then if it's causing issues in other domains, then, you know, in other professionals who's domains, who's scope of practice that falls within, you know, might be able to address that if needed. And I think that's where the functional assessment becomes really important because we're actually looking at how is it impacting them in a way, like, is it affecting their nutritional intake? Is it affecting their, you know, ability to achieve the hydration level that they need or whatever it is? But I agree, I have had some children. I'm thinking of one specifically who had cerebral palsy and the tongue thrust was significant enough that everything came out. And so we did have to specifically address that. Like, okay, we're going to work on that part. But I've also had a child, another one I'm thinking about, who had Down syndrome. And would very oddly, would only do that tongue thrust swallow when it was liquid. So on like, a straw or an open cup or something. And I really think part of it was like stabilizing. And would use that tongue would come out and kind of like, suckle off of the straw, instead of using the lips, would kind of use the tongue there. Or if we were doing puree, there was a very thin puree, you would see it. But untruable solids, it wasn't really there, which was interesting. So but from a functional standpoint, it wasn't it wasn't affecting our ability to orally intake what we needed to. Absolutely. That makes me wonder as well about whether that child might have been doing some tongue pumping to initiate a swallow on liquids because she wasn't getting sensory input. And whether then the intervention is about the sensory input rather than the tongue thrust, you know, it's not that we should address the behavior, it's that we need to address the underlying reason. Because of that, yeah. Yes. And that's actually I'm so glad you brought up that point because I took a note over on the side while we were talking because I wanted to make sure to not forget was that the other part we have to consider when we are completing these assessments is why are these things occurring. So if we are observing, you know, an oral motor deficit, we're seeing that the child maybe has decreased labial activation, they're not able to maintain a seal around the straw to be able to suck or we notice that there's decreased tongue, you know, legal lateralizations. We notice, you know, whatever it is that we see that's going on, we then have to take that information and say, okay, what are the possible wise that this is occurring? Because I think that also plays a big role in establishing a plan of care. Absolutely. I had a little girl who I started seeing last year and she was having real issues with tongue lateralization, she was 10 months, really significant. And initially I thought, well, maybe this is an opportunity thing because she'd had significant weight issues and so parents were using a lot of purease because they just wanted to get the calories in. And so we did a couple of sessions where we talked about introducing some other appropriate foods that we give her the opportunity to develop tongue lateralization. Still just wasn't happening. And I was like, I wonder if this is an anatomical restriction, like a tongue tie. As it dropped to the A and T and the A and T said no, not a tongue tie, but I think this child needs a genetic assessment. I was about to go neuro. Yeah, absolutely. So she had a genetic assessment and feeding had been the only indication up to this point and she has a rare syndrome like no other child in the world with these particular mutations. And, you know, and that led to us sort of finding out that there was some OT issues that needed to be addressed that we need to work on communication as well that she'd been she was slightly behind her gross motor milestones but now she's in physio because you know we're expecting that to continue. So yeah, I think it's interesting to always interesting to dig around a little bit and figure out what the underlying issue is. Definitely, I do find oftentimes like you mentioned that it is that lack of opportunity opportunity to start. That's usually where I start of like, okay, you know, let's look at what is the child consuming right now, what is the history look like, you know, and then typically it's like, okay, well, maybe we just we haven't had a reason to yet. We haven't had any need or desire and then providing those opportunities often times as you've been talked about with your child with the tongue thrust with like lateral placement and practicing that can really take off, but when it doesn't, then we go back to that drawing board like, okay, but why why is this not occurring. Yeah, absolutely, and I think sometimes you know in those children where there is more of an underlying why whether it's a like a neurodcap thing or whether it's more of a you know like a delay just a delay. I think I think over offering opportunities can sometimes be an issue as well like if the parents have said alright well i'm going to do baby lead weaning with my you know sick month old and then this is not a child that you know is appropriate for baby lead weaning. So we can say are already issues have emerged there because they have had opportunities but they would not at the point where they could really check advantage of those opportunities they just went ready to learn skills yet. Yeah, definitely I think that kind of goes into that range of normal as well, you know when we're thinking about no we don't have concrete normative data but even if we're thinking about you know about curve and what that looks like there are children that are you be on both ends of that you know there's going to be the child that. Quickly picks up everything and has like a rotary pattern by 10 months old and they're just killing it and then you go to the opposite side where you know maybe that vertical pattern hangs on a little bit longer and you know we we do have a tongue thrust and tongue protrusion longer than we would you know typically see and using quotations we don't we don't really know what's typical but. And so we have to think about that too that there is that that range where you know there might be the child that just isn't ready yet or there may be the child that was ready just wasn't given the opportunity. Absolutely yeah and and it's really hard new answer work to work out what your child is ready for it textually appearance on change that. When I first started doing feeding work I was in an outpatient clinic and a lot of the kids I got in were texture transition kids and at that point I didn't have kids my family we didn't have kids in my family I you know had been around a lot of kids but mostly kids with developmental issues. And I really developed this idea that there were foods you definitely shouldn't give kids at a certain age like of course they're having problems why would you give orange to an eight month old it's so car bris. And now you know with a few more years I'm under my belt I'm like no summer my thoughts are totally fine with orange and and you know all of those virus textures but I just saw so many kids who were not ready and were just. A lot of them didn't have some unknown underlying issues they were just on as you say the lower end of the bell curve in terms of our motor skills and they just needed a little bit more tailoring with the foods that walk. Yeah definitely it's funny you say that because I feel like for a lot of parents unfortunately the like marketing of foods and like how they're presented the different levels of baby foods and things just. And I really do not relate to the skills we are seeing in these children and so I think oftentimes as well that can be scary or i've had parents tell me as well that well we didn't start any chewable salads because they don't have teeth. I didn't think they'd be able to do anything because they don't have teeth and I think sometimes there's just that lack of education which then leads to those lack of opportunities oftentimes with those children that you know as you mentioned don't have another developmental disorder going on that's causing these issues. So that's the way yeah the marketing of baby foods into yeah it just goes so quickly to a mixed texture where they have to lump sort and I this is one of one of the resources I find most helpful from the s os program is their texture transition. And I think that's the most important difference between the different types of foods that you can see in the video. It's a pretty it's a pretty big jump to go from the smooth to the lumps. I mentioned that as well because I think there's also for some of my children that are a little bit older so if they're over 12 months old and you know that they maybe haven't had much of any foods or they're only doing very smooth purée and the parent is trying to transition them to let's say like a little bit of a chunky texture things like that and it's not going well. And oftentimes find as well that just going straight to the real soft solids is a make a big difference as well because once you get into that you know over 12 months there's that level of like can we build on this child's independence a little like would they just prefer to have a whole chunk of banana. You know navigate versus you hand mashing and making it kind of chunky and mushy and they're just not interested in it because that's just not as fun and that's not what mom and dad are eating and that's not what grandma's eating and grip you know and. Absolutely no I think I think that independence can be a huge and not not necessarily always over 12 months either you get under 12 months who just do like being spoon bed that does very independent little spirits and yeah you can see big changes when you just start offering appropriate. The finger foods that they can they can self feed and this is a thing where I get constantly getting ideas from social media about how to make foods more finger feedable like using the cripple catas and you know spring you know baby cereal on the outside of the avocado so easy to pick up and yeah some great ideas out there. No definitely any other thoughts before we kind of go into some of our key examples of when we're thinking about oral motor skills. I don't think there's anything in particular that I I want to say I guess I guess it's it's useful just to mention that there are a couple of tools out there. I'll motor assessment so I mentioned the so much sadly that is no longer commercially available maybe one day somebody will redevelop it. Just in during checkers did yes tall decided to sort of survey was not available for a few years after she passed away but it's just become available again you can now do to online training to get trained up in in applying for and storing system for our motor there's the chumps from from the block research group. If you do applications for funding I think it's good to be aware of the edX as well which is it's like the GMF CS but the eating and drinking so the GMF CS where you rate gross motor function as a way of. So quantifying how severe is there a calls is in a child e that's similar thing where I think it's a five point scale and you can quantify how severe sort of our motor feeding difficulties slash dispager are in a child. So that I think some of those sorts of things can just be helpful to know that in case you need scores for insurance or other types of funding. Yeah that's a great point because I think sometimes that is one of the areas that's difficult with feeding and swallowing is that we really don't have like standardized assessments that we can use to show scores to insurance and they love numbers. Thank you. So that's a pretty straightforward one if you're maybe to apply and it's great. Yeah feeding flock is a great resource for all the tools they're great very generous and yet the really nice. Tools that can give you data that's really useful for the funding. All right well do you want to do your case first or do you want me to do mine please so this case was just so interesting to me so this is a little three year old boy. withologists. working out in the community will say, "I've got this kid. I'm really confused." Or, "I just need another pair of eyes to make sure that I'm on the right track or some ideas or whatever." And so I'll see the client for one session or a couple of sessions and then liais back with them about the client. So this was one of these clients. And he had come to me at three after 12 months of speech pathology focused on his communication. He didn't have very many words. And he had made some progress but pretty minimal. A lot less than the therapist was expecting given her other clients and the results that she usually got. She didn't feel that there would sort of develop mental, like common developmental conditions at play. So she didn't feel like he was presenting in a way that was consistent with autism or in a way that was consistent with global developmental delay. So just really confused as she thought, is there something sort of or my own functional going on with this little guy because he was a little bit of a picky eater as well. So she thought maybe she was missing something. So he came in to see me. We did a big case with Drew with mum. He had had major major newborn feeding issues. So it had been hospitalised twice. The failure to thrive. He just wasn't gaining weight and just was a very poor feeder as a little guy and mum was still carrying some trauma from that because essentially she'd gone into hospital with this very difficult to feed baby and had been told, he's just a faulty kid. He's just a disregulated baby. It just is what it is. Just go home and keep doing what you're doing. Which is awful. I'm sure I was just keep pushing the volume. We're not focusing on the quality of the feeding experience at all. Yep, that is absolutely what it was. And I don't think that he even saw a spiritual psychologist in the hospital. I think it was just like a medical admit and yeah, very hard for mum and for this little guy as well. So he was then referred in for spiritualgy for being a late talker. He had very few words. We did a few different things. So we had a slightly longer assessment session so we could fit some things in. So we did just simply an agent for pre-nemic infantry. We did an oral meth exam. We used our picture cues. He was very able to sort of follow instructions. Mum had also very kindly brought in a lollipop to help with some of the target targets. So that was lovely and I watched him eat. So in terms of his communication, he didn't have very many words. The words that he did have, when I went back and looked out at after, because I didn't pick this up at the time. But the words that he did have all of his sounds by labels or liquids. There were no lingual sounds at all. When I, when we did the oral meth exam, structurally everything looked pretty good functionally. When we tried to do lateral movement, he could do it to one side and not the other, even when we used the lollipop. He just didn't seem to be able to go to that particular side. And then when he was eating, he was pretty, he was really functional actually. He had skills that looked really good. But then when I was watching closely, I noticed he was only chewing on one side. So he wasn't, he wasn't lateralising the bolus to both sides. He was constantly moving up to one side and then and then swallowing. And so I took full of this data and then, you know, I said to him, well, I was like, I need to think about this. And I went through it all and there was obviously there was a pattern emerging there. No lingual sounds, no movement of the tongue to one side, either in the in the task where I was just asking him to do it in a deep contextualised way or during chewing some food that should have required lateralised into both sides. And so this was one where I was really chasing the Y and really interested in figuring out what exactly was happening here. And I ended up digging into his medical data with the, along with his his regular speech pathologist and who had actually been to a petty chisening for some tests. They hadn't had a meeting with the family yet, but they'd done an MRI and they'd found that he was missing one of his happy glistening moves. It was just like that. Wow. Wow. Yeah. That explains everything. So he just, yeah, he had the innovation on one side of his tongue but not on the other and that was just a genetic thing that had just happened. And and yet everything kind of came together, but I, it was just a really nice example, I think of how I got data from speech that corroborated data, I got from feeding that corroborated the data I got from the sort of formal or part of the exam and all of those. I won't say it didn't expedite a diagnosis that was already on the way, but it was all very consistent with a really rare and interesting sort of check. So yeah. I agree. That's a great point as well because if we are having oral motor difficulties, we should see that across board with what we're doing. So, you know, if we're seeing just issues with like one part in one activity that, you know, that might tell us something else is going on versus the the very specific oral motor skill because that's what we really should see across the board. Yeah, absolutely. And I, the second part of my PhD was assessing a whole bunch of three year olds and I did the, the oral motor subtext of the date from these three year olds, which is all de contextualized, you know, a kiss and then blow a waltz, blow in them smile. And so many three year olds could not follow de contextualized instructions for oral motor movements. They just couldn't do it. And that was including. So half of my sample was children who were born at term and had no known sort of genetic abnormalities. And obviously a percentage of those would have had developmental issues because it was a population sample. There were plenty of kids there who had who scored normal on their speech assessment, normal on their language assessment, but couldn't follow an instruction about oral motor tasks that they're lives. Yep. Yep. I think that's yeah, that's why I'm I'm a huge advocate for doing it a functional assessment taking into account all of that because it can, it can really tell us a lot more information. That's actually why I bring up my case study that I wanted to talk about. So this child came to me at two years old and had been seeing another therapist for a couple months before and the therapist that they were seeing just didn't feel they were equipped enough to continue seeing this child. This child has diagnosis of spastic quadriplegic cerebral palsy was born at 33 weeks with a grade four hemorrhage that they had right at birth. And so for the the therapist that was seeing them just felt like it was just out of her wheelhouse and I honestly respect them for saying, hey, not. Yeah, like I'm not. This is you need to go somewhere else. Well, the kids that I don't feel equipped to assist. Right, right. So when child came to me was being seen by a variety of professionals, ENT, neuro pulmonology, neurosurgery, OTPT, ophthalmology, like we we had the wheelhouse covered. But was coming because we are now two years old in one month and what was still on bottle and was not advancing to open cup, straw cup, sippy cup, even like just bottle with foods was doing purees. Only any of the chewable solids the child was being offered would just swallow whole. So mom had pretty much said, I'm not really going to give them any because we're just swallowed like there's no chewing happening at all. So when they came in for the session at this point in time mom is worried about weight gain. This child does not have a feeding tube at all. So everything is coming in orally, but it's through the bottle. So she's doing like formulas, really heavy like milkshake mix kind of things just to get the calories in. And so when he came in for the oral motor exam, the child was super, super sweet. We didn't have any words at the time. We had very minimal vocalizations overall. However, receptively pretty good, pretty good with following simple commands. And so we kind of just played for a little bit so I could get an idea of what we might be able to follow. And he was pretty receptive to everything. And I was like, okay, it seems like from that cognitive level we're about a two year old, which is great, which is great. And so did the oral motor exam really during feeding trials? Just show me what this looks like. And with the bottle because that's kind of all we were doing for drinks, we were okay. I mean, we latched. We sucked on the bottle, but a lot of spillage. You could just, there was just a lot pouring out of the mouth. So we really didn't have good labial seal on there. It was constantly breaking. It just was pretty messy. And mom had said like, oh, you know, I always have to put like a bib underneath and just catch during those feeds. And then with the spoon feeding, we actually did okay. You could just tell it was like bite swallow, bite swallow, like just not really processing any of it in our mouth, even if it was a larger bite, smaller bite, like we just tried to immediately swallow. For the world motor exam mom, I had her go ahead and bring in some of those chewable foods she maybe had tried. And she had done veggie straws and spaghettios. And so we tried with the veggie straw at first and with like lateral placement to see like, okay, well, what's going to happen if we do would bite and then just suck on it, suck, suck until it was mushy and then with swallow with spaghettios, do we just swallowed those whole there was no there was no chewing going on. And so it was interesting though because with this child, you know, immediately I'm noticing like, okay, we don't have good lateralization and even trying it in a more decontextualized way because you know, nervous about this child swallowing everything whole. I don't really want to test them too much with a solid food of like, are we going to lateralize it or are we going to try to swallow it? And so trying to do some decontextualized movements, it was interesting because like no tongue movement at all. Like, hey, can we try to like over here, you know, putting some like stuff on the spoon and bringing it over. Can you come get it over here? I mean, just none at all. And it could be that much. Yes, like, child, like, I don't know what you're talking about. That's not going to happen. But I love to bring up this case because we started working on increasing those opportunities, you know, offering more and more opportunities to lateralize, practicing biting, you know, let's, okay, let's do it in tool first and then we'll progress to slightly, you know, small pieces and work from there because mom's really nervous about that. Let's let's move away from the bottle. Let's do some more advanced drinking skills. And he picked up on those very quickly. But I like to bring up this case because fast forward, you know, a year and we're eating a variety of solids. We're doing really, really well with everything. And I actually, for the purpose of my course that I have was like, I'm going to redo an oral motor exam on this child. And so we're getting ready to redo this oral motor exam. And I'm like, okay, I want to show the difference between doing a decontextualized oral motor exam and one during a functional task. And I didn't, you know, I, he, I'm not warning him at all at what I'm about to do. But I take, you know, like a little oral motor probe and I'm like, okay, like stick your tongue out. Okay, can you move it over here? Moot over there? And he literally just looked at me mouth open, did not move the tongue once. So if I had seen that, I would have been like, okay, poor lateralization. We wouldn't know, you know, poor tongue protrusion. We can't. And but then I, you know, do it again with like, okay, let's take a bite and at the, on that day, he had a rice crispy treat. And he took an anterior bite, lateralized with his tongue, chewed and swallowed. And so it's a perfect example of if you only look at what you see during that decontextualized very structured oral motor task, it's not going to give you the whole picture. And so yes, it might give you a little inkling of it. But just like you said, you even, you know, were assessing children that didn't necessarily have something going on with their feeding skills. And they are like, I don't know what you're trying to get me to do. Like, because if someone tries to tell you like, hey, go do this, and it's not something you normally think about doing or consider doing outside of context, it can be really difficult. But I love to bring up the case because if that had, if that trial had come in, like that initially, we probably would be like, oh my gosh, we can't offer any food. Like there's, there's no way we could do food. We can give them, you know, like let's just do purees. But we have to give those opportunities to see what they can do when given, when given the chance. Because I think it can shed a lot more light on what they can do from an oral motor perspective. And I think, you know, and I know this is going slightly beyond what our topic for today. But I think that there's some really important takeaways there for therapy as well. But if you, you know, if a child can do something in a functional context that can't do it in a non-functional context, why would we teach that skill in a non-functional context and expect that that would be useful for a functional context? Yeah, exactly. Straight to the functional context. And I think too, it goes into that like task specificity of teaching. We think about those motor learning principles of me sitting there and teaching him how to lateralize that tongue over there to that probe. We can see that that wasn't needed to generalize over to lateralyzing a bolus to chill. Like that skill isn't, you know, it's not actually going to translate over there. And so I think that's important too, where and you know, this is kind of getting off, off, off on a tangent as well. Because you know, I always get the question of like, well, what if they don't accept food? How are you going to do it if they don't accept any food? Okay, well, I always think of it almost like food chaining, but in the opposite effect of like, well, let's skill chain it. So let's think about where they're out. Okay, if they're not accepting food that we can try, will they accept it in the tool? Okay, they won't accept it in the tool, you know, like in tool or cheesecloth, will they accept it off of something else that they can, you know, then maybe then we are introducing something, but still trying to make it as close as possible, and then as quickly as possible eliminating those. And I think that, for me, I like to think that way backwards, because oftentimes a child surprises me on when they can do versus saying they can't chew, I'm going to start at that lower end with, you know, decontextualize passive, or I shouldn't say passive, but like decontextualize active exercise of cheering when maybe we could have already been up a couple steps higher. Yeah, yeah, absolutely. The other, because I get asked that question all the time as well, like what if they won't accept the food, like how do you, how can you work on it functionally then? That's the other question I ask, and I don't think this is all kids, but I think it's a lot of kids is if they won't accept the food, then maybe accepting food is a goal before oral motor actually expert disease. Maybe you need to work on, you know, I'm so excited. Absolutely. Yeah, absolutely. And I'm like, well, then maybe your report building and their relationship with food and, you know, their anxiety around the meal, like that has to come first, because if you don't have that trust and relationship, you can chew on a chew tube all day, but that child's still not going to go eat food. That's not going to translate to them wanting something else in their mouth. Exactly. You have to go more bottom up and yeah, and work on, on absolutely, as you say, that relationship. And I think there are some kids where, you know, oral motor skills and acceptance just get really enmeshed. And as you say, for those kids, I think, I think, chaining it as quickly and as closely as possible is a really nice approach. But often when, when, when I think about kids where the reason that they couldn't do functional oral motor practices because of acceptance, I'm not well then acceptance is where we need to start not on a day contextualized oral motor task. I agree, because I find that taking that approach with many children that I might even see some oral motor things going on very quickly catch up because now they're just happy to be accepting food and those opportunities are now offered so they can progress the skill. Exactly. And they're practicing it six times a day because, you know, if they're just they're eating differently than they were before and that's a lot more powerful than anything that we can do in our, you know, in our few sessions or one session a week. I agree. I agree. Well, is there anything else to add? I feel like we covered. We covered a lot. Which is great. No, I think I think that's everything. I yeah. I just yeah, I just think, um, calibrating your system by looking at as many normal kids speed as possible. And, you know, and if you have a scoring form or, you know, or an observational sort of form that you use the first scoring the way that kids eat, like use it on typical kids and see how they come out just to just to figure out where those things sit. I think that's, um, that can be really powerful. And just thinking thinking in terms of effectiveness, efficiency and acceptability and just keeping on coming back to those things. And, um, I think you can't, sorry, can't go far wrong when you keeping those in mind. Yep. I agree. Well, thank you so much. I appreciate you coming on here and chatting with me again. Um, it's always such a pleasure to have this session. Thank you. I really enjoyed it. Thanks for tuning in to the feeding pod this week. If you enjoyed today's episode, please don't hesitate to share this podcast with your friends and colleagues and leave us a five-star review wherever you're listening from. If you're interested in learning more about pediatric feeding and swallowing, be sure to follow Bri, me on Instagram at pediatric feeding SLP or check out my website where you can get access to more courses and information. www.pediatricfeedingslp.com. Again, thanks for being here and listening to my aramblings, and I hope you'll keep listening. Until next time, cheers.