Goosebumps: Choose your own adventure in Pediatric Feeding Disorders


Brianna Miluk: Hello, hello, and welcome to the Feeding Pod. This is your host. I'm Bri, Brianna Miluk, and I am a speech language pathologist and certified lactation counselor. I specialize in infant and medically complex feeding and primarily see patients in the home health setting, although I do have some that I see in outpatient or via tele practice.

I'm also an instructor at the university level and a PhD student studying communication and information sciences. I have a huge passion for evidence-based practice and supporting information literacy in speech, language, hearing, feeding, swallowing sciences specifically as it pertains to social media and translational research.

This podcast is meant to share anything and everything related to being a pediatric feeding SLP, feeding therapist with sprinkling in a little bit about working in academia, being a PhD student, and how to access, appraise, and implement research into clinical practice. 

Some episodes may contain guests, and I'm already looking forward to some of those coming up, while others might just be me rambling about something that's been on my mind. Regardless, my goal with this podcast is that you walk away not just with newfound knowledge, but with the inspiration to think critically and not be afraid of research. So, without further ado, let's get into today's episode.

Welcome back to the Feeding Pod. This is Bri and I'm just gonna apologize in advance for my extremely stuffy nose and my hypo nasality. It's just gonna be part of it today, and we're just gonna, we're just gonna deal with it together. I am back with Tovah Feehan today and she, we're gonna basically go through a part two of our critical thinking with pediatric dysphagia and talk about what you can do to support your critical thinking skills.

You know, what, what is implementation science? How can we support information literacy, especially in this age of everything being fast and quick and digital, and social media and online? Really trying to bridge that gap to support clinicians in evidence-based practice and, you know, which in turn supports our families and, and our clients. So, Tovah you know, how are you? Welcome back. 

Tovah Feehan: Hi. Thank you. 

Brianna Miluk: I'm so happy to have you back here and, and for us to get into all of this stuff, so. 

Tovah Feehan: Me too. 

Brianna Miluk: So Tovah if you will kind of give us an idea, you know, you took us through like your progression of like building your critical thinking skills as a clinician, your experiences, but give us an idea of like, where are you at now? What are you doing now as a speech language pathologist? Like, tell me, tell me more. Tell me more. 

Tovah Feehan: Okay. Isn't it weird to talk about yourself? So, I'm a speech language pathologist, duh.

I'm a certified lactation counselor. And, I left after many years at a children's hospital to start a private practice where I specialize in feeding challenges of all varieties, mostly infants and toddlers. And I see a little bit of early language too. And those are really my passions and I love so much just partnering with families and partnering with other providers to put together the pieces of the puzzle for each kid. And I teach dysphagia for Widener University, which is an awesome program and they've been so open, as far as critical thinking, like adapting and growing and changing, to meet the needs of the students. Should I talk about GET Cafe?

Brianna Miluk: I was about to say, there's a little bit more, it's a little bit more to you.

Tovah Feehan: Yeah, so, there's a place called GET Cafe in Narberth Pennsylvania, I should say, where I'm in South Jersey outside of Philadelphia. But there is a cafe that, my husband and I were able to help start probably about 10 years ago, with some amazing people. And it was a family that I met working in early intervention actually and their son has Trisomy 21 and they wanted to start a business that would employ adults with disabilities. And so, it's grown a lot and now there's maybe between 40 and 50 adults that work there. And it's just an amazing place. Like you leave and your face hurts because you're just so happy. And, I've learned a lot because most of my experience has been in pediatrics to, so to see, adults and challenges they face, or fears or problems that their parents have.

And also, to see, their victories, you know, and the things they enjoy and the friends they make and all of that stuff. It's, it definitely gives a broader perspective and informs me even working with them at a different age. 

Brianna Miluk: Wow. Yeah, I think that's, you know, even just like that, that experience alone probably did help in turn with some of your critical thinking, especially like, I'm thinking about like goals and when we're writing goals, like even early on.

Tovah Feehan: Oh my gosh yeah. 

Brianna Miluk: We need to be thinking like long-term, why does this matter? And so much of that is like, I mean, parents think about their child as an adolescent and as an adult so early on, and being able to like, help them with that conversation and, and through it all. So that's very cool. If I'm ever in the, you know, nor- North Jersey, is that what you said? East? North?

Tovah Feehan: So, I'm in South Jersey outside of Philadelphia. 

Brianna Miluk: South! Okay. 

Tovah Feehan: So that's where my office is, Pediatric Feeding Partners and then the cafe is called GET Cafe, and that's in Narberth Pennsylvania. Widener University is also in PA in Chester. 

Brianna Miluk: Okay. Okay. Well we have that, that Pennsylvania connection because I teach in Pennsylvania, Western University. And I also can harp on that school being very amazing in, you know, talking about like, they now have a course, which is one of the courses that I teach on information literacy and CSD and being able to like, talk through all of that and how that applies to our patients. So, I love to see that. I love to see universities making that push toward it, so.


Tovah Feehan: Yeah, for sure. And what you said about goals resonates a lot too because it really shifted how I think about even neurodiverse affirming practices and how much I had to learn. Just seeing the goals, quote unquote that they needed is mostly like self-advocacy. And finding people who had shared interests with them that they could be friends with or create relationships with was really what was valuable to a lot of the employees there who wanted to work on different things.

Brianna Miluk: Mm-hmm. Yeah, and I think sometimes we forget that those are skills we can work on early on. Like even when we are working in that, early intervention or birth to three or like, you know, early school age, like we should be targeting that, even then, so. 

Tovah Feehan: Yeah. 

Brianna Miluk: Very cool. Very cool. Yeah. Well, thank you. Real quick, if somebody wants to, I'm gonna ask you this again at the end of the episode, but. 

Tovah Feehan: Oh.

Brianna Miluk: If somebody wants to contact you or find you, like, are there ways that people can, you know, see, see your clinic and what you're doing?

Tovah Feehan: Yes. So, my website is and then I'm on Instagram @PediatricFeedingPartners. Those are probably the easiest ways to, to reach me. 

Brianna Miluk: Perfect. Yeah, that sounds, that sounds great. And I'll make sure to put that in the description for anybody that's looking for it. So, if you have extra questions or if you're in the area, need some services, then can reach out to Tovah. 

Okay, So let's shift, now let's shift into talking about how to build critical thinking skills. So now we're talking about like, right, you can learn to be a critical thinker, but you do have to be an active participant in this process. You have to acknowledge like this is something ongoing. So, let's talk about this. Let's talk about them. 

Tovah Feehan: Yeah. I have a dear friend who would tell me that I think she actually, she accidentally DM'd you. She meant to message me. 

Brianna Miluk: Oh yes! She did! 

Tovah Feehan: So, she talks about how- 

Brianna Miluk: And then we started talking. 

Tovah Feehan: No, she's, she's amazing. So, this dear friend mentor, she would talk about how like you have to make your own pearls in this field. Like there's so much that we can accomplish, that we can contribute to our field of speech language pathology, but it's really about like making those pearls for ourselves. And I just love that analogy so much. 

Brianna Miluk: No, I love that because she texts me or DM'd me and said like, big pearls. And I was like, I don't know what that means. 

Tovah Feehan: I love it. I love her so much. But yeah, I think that's part of it too, is like we can always find reasons why things are hard. And I know like our jobs can be hard and there can be like burnout and overwhelm and like feel overworked, but also trying to find ways to, to build in those opportunities for yourself to keep growing.

Cuz I think if you can do that and find ways to be excited about your job, that it really helps with that feeling of burnout. And or like looking like maybe you're not in the right. In the right setting or the right thing. Like if you're miserable all the time and you're kind of stuck like, I don't know, do something else.

There's so many things you can do in our field or like literally do something else entirely. But. 

Brianna Miluk: No, I agree with that. You know, that's thinking about like the, the and I know we're gonna talk a little bit about these mu- not as much, but like like the sunk cost fallacy. Like, just because you've spent a lot of, do you know this fallacy?

Tovah Feehan: Oh. 

Brianna Miluk: Okay. So, the sunk cost fallacy is basically like this bias we have to continue on a path because we have spent time, energy, and money on something. When the rational thing to do would be, Hey, this isn't working. Or, Hey, I don't like this, I'm gonna walk away. But sunk cost fallacy is where we're like, oh, I already did so much for it.

I think that I should like, so if you're in a situation, right, like you're like I am working in blank setting and I'm miserable, but I've been here for 10 years. Do I really wanna like, ugh, step away? I put- it's like, yeah, step away if you're miserable. Like if you are not happy, be gone. We have so many options in this field.

And that's really hard though. You know, that's a cognitive bias. That's hard. I totally, totally empathize with that. It's really hard. Or if you spent thousands of dollars on certain, like certifications or, you know, intervention methods and you're like, wait, this doesn't actually work the way I thought it would like. It's okay to pivot. But it's hard to do. Hard to do. 

Tovah Feehan: I, my practice is always growing and changing and there are things even that I was recommending like a few months ago. There's like one thing in particular where now I'm just like, oh, shoot. Like no, I wasn't, yeah, I'm gonna, we're gonna put that away now.

So, I think like, being okay with making mistakes is actually a really big part of critical thinking. And I try to model that for the students that I teach too, because I definitely make a lot of mistakes, even as a professor, like the way that I might think I'm communicating information really clearly.

And then I can tell based on the feedback that I get that like, it wasn't, you know, so owning that or owning if I like post something wrong or I like grade something wrong, like. If we can model like, yeah, I made a mistake. I'm learning, I'm figuring this out. It makes it okay for other people to feel open, to make mistakes and to ask questions as opposed to like, I am so confident and 100% right all the time.

That's also a red flag for me. When people like, have all the answers, I know all the things all the time. I'm like, Hmm, I don't know. I don't know about that. 

Brianna Miluk: Yeah. No, I, I agree and I think like recognizing that like, it is okay to be like, you know, I, I'm not 100% sure about that, but like, I'll do my best to find out.

Like, I will start, I actually, someone messaged me and I have a post I'm gonna create about this coming up. It'll probably be out by the time this podcast episode comes out. But someone messaged me and was like, what's the research actually say about mealtimes having to be under 30 minutes? Like we all say that.

But like, do we actually have, and it's like one of the, and I literally messaged them and I was like, okay, here's what I found. And I like pulled up all this stuff and I'm like, but literally thank you so much because I just went down like the deepest rabbit hole because that is one example of something that I'm just have always said and like, you know, is that one necessarily like, you know, thinking risk of it, is it that bad or that big of a deal?

Maybe not. But also, like you have to recognize when something maybe isn't exactly as it seems, right? So, like we have sometimes standards or things, but like, it literally happened like two days ago and I went on this like deep, deep hole trying to figure out like there was, cuz there was just so many like anecdotes on mealtime should be under 30 minutes.

But like, because why? Like what are actual mealtime averages? How long do mealtimes actually last for majority of people? And I just thought that that was so interesting. 

Tovah Feehan: Yeah, it is really interesting. And it's one of those things, like teaching has made me such a much better clinician because when it comes to that, why I have to understand what the research says about it and what my rationale is for whatever I'm teaching.

So, it's making me question myself like, wait, why do I do that? I haven't thought about that in a while. And like figuring out it's hard to, it's hard for us to find in ourselves those places we're on autopilot. Cuz we're on autopilot. I think it maybe takes, I don't know, what does it take? Slowing down or. 

Brianna Miluk: Slowing down I think is huge with critical thinking.

I talk to my students about that in information literacy class all the time. I go, majority of the time, you know what's rational, you know, what makes sense. Like, you know what the red flags are, but if you are on that fast autopilot, just scroll, scroll, scroll, quick Google search, click a link. And just like you don't flow down for a moment.

Tovah Feehan: Mm-hmm. 

Brianna Miluk: You're gonna forget because part of like cognitive biases is heuristics, which is those mental shortcuts. Your brain wants to go the fastest way possible to make a decision. And- 

Tovah Feehan: I wanna tell you that a lot of times when you're talking or when I read your posts, I have to Google things. Cause you use these words. And I'm like, oh yeah, that's real interesting. I'm gonna go see. 

Brianna Miluk: You're like actually I have a podcast episode coming up. That's gonna be on a bunch of different logical fallacies and cognitive biases, and we're gonna like, go through specific examples in the feeding and nutrition world. I am so excited.

It's with Steph Compton, Dr. Steph Compton. She's a PhD in the like nutrition science world. And I'm so excited about it. But yeah, but like, I mean, our brain wants to go with the path that's easiest, but sometimes we have to slow down to make it go on that other path to say, wait a minute, is this actually. Something else that you said that I wanted to reflect on a little bit is, you know, you talked about how like teaching has helped you so much with like questioning why and reflecting on your practice.

And I definitely want to encourage people, like, one way to improve your critical thinking isn't necessarily through, through like teaching a class at a university, but like even supervising and mentoring is -

Tovah Feehan: Yeah, for sure.

Brianna Miluk: Huge for that. Like, I think any interaction you have with clinicians where you are providing that type of relationship, like you're, you're in a mentor-mentee role, I think.

Tovah Feehan: Yeah. 

Brianna Miluk: Refines that a lot. 

Tovah Feehan: And I think the flip side too, like what I'm hoping is that the students that I have, I'll tell them like, you might go out to a placement and your supervisor's gonna ask you to do something or you might see something that's very different than what we talked about in class.

So look to like you, like I'm not, God, I don't, I'm just giving you the best information that I know, but like, see for yourself, ask questions, like look into the resources that they have but setting them up so that from the outset it's not like, oh, my supervisor is like the authority on this. Like, we're figuring this out together and our field is always changing.

So, you know, as a student or a young clinician, you might be able to teach your supervisor or your colleagues something. 

Brianna Miluk: Yeah, absolutely. I think that's a big one. And so that we're like, our role as instructors or supervisors should also be to insight that type of questioning and learning so that like our students and our student clinicians do the same thing.

Like any time, I've worked with a, a student or a student clinician, I'm always. Please literally always ask me why, even for something small, if you're like, eh, I don't think that really matters. Ask it. Like- 

Tovah Feehan: I thought it was gonna be something with your hair. Cause you just moved a hair. So, I thought it was like, 

Brianna Miluk: I just moved a hair. No, it's just in my face. It's more, it's like, just ask it or say like, Hey Bri, I thought that was approach was interesting. Why did you implement it? And like, where can I read more about it? 

Tovah Feehan: Mm-hmm. 

Brianna Miluk: Where can I learn more about like how you applied that or why. And kind of like expanding off of that too, because I hope that students take that into, like you said, all the other settings.

Because again, I don't know everything. I don't, I'm- this much of the like- all the things there is to know. 

Tovah Feehan: I would give you like a few more inches. You should just like gestured like a half an inch of knowledge. So. 

Brianna Miluk: But you know, there's so many different settings. And even like, even if I'm doing home health in South Carolina that looks different than home health in New York City and home health in Texas and California.

You know, like, so even within that, everyone's gonna bring different experiences and so recognizing that of like. 

Tovah Feehan: Yeah. 

Brianna Miluk: So many people can bring other things to the table, but that open discussion I think is important. I wanna shift a little bit cuz I wanna hear you talk about how you navigate thi- thinking critically, especially if it's something that you disagree with.

So maybe someone is providing an approach and you're like, Hmm, that's weird. I don't, I don't really agree with how they're applying that. Or like, is it that I disagree or is it that I don't understand it? Or like how would you approach that type of situation with a colleague? Whether it's someone you're working with or like, maybe it's another I'm thinking about I feel like a lot of times we overlap with like occupational therapists. I get this question a lot. Like the OT is doing this thing. And I don't totally agree with how they're approaching, you know, this situation. Like how might you start that conversation or what might that look like? 

Tovah Feehan: I have a good example of that and I hope I don't butcher it. Cuz it was a while ago. But I think, okay, so first the answer to the question is if I, if my guard goes up or I don't agree, then I wanna ask questions instead of coming at it from a place of judgment. I wanna come at it from a place of curiosity because I definitely don't know all the things and I don't know for sure all the other like perspectives and disciplines and specialists.

So, an example would be GI so there was a baby, I don't even remember who this patient was, but I just remember the situation where the baby was on reflux medication and the parent was asking about Enfamil AR, which is like a formula that's often used for reflux. And it thickens when it mixes with your stomach acid.

And I just didn't understand. I'm like, why wouldn't he want her to be on that? Like, she has reflex, this would help, blah, blah. So, I did feel a little bit of like, man, like what? What's, yeah. So, I just went to him and asked, and I learned so much, and I learned that because they were on an acid suppressant that the formula actually wouldn't thicken.

And I didn't know that at the time. And so, I could have done damage if I like, try to be a know-it-all, or if I'm like, I think I know best. I'm like, well, I think you should, instead of like asking questions and learning something new. 

Brianna Miluk: Yeah, I think that's great. And that's, you know, kind of goes into the things we talked about in the first episode about like, calling people in versus calling people out. Like by calling in, you're asking people. 

Tovah Feehan: Oh, I like that. 

Brianna Miluk: Yeah. Yeah. Call people in. So, like you're asking questions, you're saying, I wanna know about it from your point of view. Can you show me where I can learn more about what you are doing or how you're applying it? Or could you tell me why? Sometimes you find like, wow, actually that does make sense.

And like, I now know why you're doing the thing you said, just like in the situation you just talked about, it's like, oh, cool, thank you so much for explaining that. But if we go into it of like, I just don't think there's any possible reason why you're doing this. Like, what are you doing? Why would you not, you know, if you approach it in a way that's more like in a defense position versus just like offering.

Yeah. Then I think that's kind of, kind of where that plays a role. And you, you know, a lot of times when if I'm in a different- difficult situation with like, you know, maybe I'm providing feeding therapy and an OT is providing feeding and we're both doing it, a lot of times I'm opening up this discussion to say like, I wanna make sure we have continuity of care.

I wanna make sure that what I'm doing overlaps with what your goals are. I would love to collaborate so that like we can both be targeting similar things because feeding is a sensory motor experience, like we need all aspects involved. And so, you know, if you open it up of like, what are your goals?

What are you doing? Here's what I'm seeing, and just like collaborate in that manner. A lot of times you can come to that same page of like, oh, here's what I was thinking. Here's why I was thinking that, here's how I would maybe go about it. 

Tovah Feehan: And the same, it goes both ways. Because if people ask a question instead of being like defensive or judgmental of their question, like taking it as an opportunity to like teach something new.

Brianna Miluk: Mm-hmm. 

Tovah Feehan: Is another one. And I think this is purely my opinion, but it's based on my observations and also just listening to different people speak on speech therapists as a whole. And I think a lot of times we're like very nice people. But it's harder to, like, it's not necessarily always the most helpful thing to just be nice.

We also have to like keep it real and be honest and there's a way to do that kindly. But I think that's, yeah. I think we run into trouble when we're either like being, like playing nice and like not being real about something when it's an opportunity for someone to grow or we're being defensive or judgmental.

Brianna Miluk: Yes, no, absolutely. I agree. And I think like opening that up and we don't like to, you know, quote unquote like rock the boat with stuff. We don't want to challenge that. But we really need to be comfortable with being, like you said at the beginning of this episode, like being comfortable with being uncomfortable.

Like recognizing that when you are uncomfortable, that is a moment of growth. Like that is when we grow and, you know, can, can work through critical thinking because critical thinking is hard and it's often uncomfortable. And so, like just putting yourself in those positions and knowing like, okay, this feels a little bit weird, but the more I grow in this area, the more I learn about this area, the more I experience in this area, the better it's going to feel. And it's not always going to feel uncomfortable. Yeah. 

Tovah Feehan: Yeah, that's important too. It does get easier. 

Brianna Miluk: Yes, it does. 

Tovah Feehan: And then there are other nights where I don't sleep, so I don't know. 

Brianna Miluk: Yeah. And then there's also that and hashtag Lexapro. 

Tovah Feehan: Zoloft. 

Brianna Miluk: I love it. And there's also medications and therapy that I highly recommend.

Okay. Let's talk about some of like the barriers to working on critical thinking and some of the things that make this not, I, I don't even know if it's necessarily a barrier, but what makes it hard? You know, we talked a little about some cognitive biases and that definitely plays a role in it.

And like I said, there's gonna be an episode coming out that talks more specifically about those. But what are some of the other things just like day-to-day within our clinical practice, that makes it hard for us to think critically?

Tovah Feehan: I'm trying to think of what other people would say because it's hard for me to answer that because I'm so passionate about thinking critically that. So, there are other things that are hard for me. Like being organized is hard for me. So, it, I think it's more so what you're talking, are you talking about like if it doesn't come naturally or like, cause they don't have time or. 

Brianna Miluk: Yeah, I'd say like, probably kind of like a, a mix of it, but even like your personal reflection on some of the things, I think. 

Tovah Feehan: Things that have helped me think critically?

Brianna Miluk: Yeah. Yeah. So, like, what was something that, you know, make it hard? I'm, I'm thinking about like you know, maybe a, a family or a physician wants like a quick fix and you're like, that isn't necessarily gonna happen. Or always trying to have an answer to something, you know, kind of going into that. Like, I have to know everything.

I'm supposed to be the expert. When in reality that can cause you to. Take that shortcut, take that heuristic versus actually stopping and slowing down. Maybe that's what I'm thinking of. Like what are some of those barriers to being able to slow down and think about it? Like if we're in clinical practice, you're in a session, what are some of those, those pieces to it?

Tovah Feehan: I mean, I think a big thing, it's not for me anymore because I have a private practice, so I can go at my own pace. But working in a hospital setting you know, you have productivity standards, you have a schedule you have to keep. And there's not, there's not gonna be time blocked out for critical thinking.

So, I think that is, it does make it hard for sure. You know, If I think about working in that setting, like asking a colleague if they can peek in, like asking if it's positioning, like asking PT, like, can you just peek in the last five minutes of my session, help me like troubleshoot this? Or asking OT to come in and help me figure out like the best way to build up a utensil or like, you know, whatever, whatever it, another speech therapist.

Like, get another set of eyes for that. I think it's super helpful. And that doesn't take too much time. I don't know what are some other ways. 

Brianna Miluk: Yeah. 

Tovah Feehan: Like it's extra. It is extra when you're in that situation and you have a high caseload. 

Brianna Miluk: Yeah, I was gonna say, I think one of the biggest ones is time. You know, whether you're in the hospital or the outpatient setting or even like home health, if you have a set time, you have to see a patient and you're expected to like have a solution during that amount of time.

Sometimes it doesn't happen right then and there. Like sometimes you take in a lot of information and you're like, oh no, like my 30 minutes is up and now I wanna like think about this later. And recognizing that it's okay to not have like a very quick, fast solution in the moment. And I think some of that is just that like reflection piece, right?

Of being like, okay, I'm gonna make a recommendation right now. I think I can, but I'm gonna think about this a little bit more. Or I need to read about this a little bit more. But the time barrier, like I think is one of the biggest ones. Cuz it's like, yeah, I'm not paid to go home and do the research on that. You know? Like. 

Tovah Feehan: Well that's where it comes in. Like what's your motivation, I guess? I don't know. Everyone's motivation is different and there are plenty of things that help me, but I don't know if other people would wanna do them or not. Like I'm happy to share them. But. 

Brianna Miluk: Mm-hmm. No, I think that's a good point is like that. Yeah. The motivation to want to look in all of those and recognizing like, that just staying where you're at is not critical thinking because like your practice should evolve and change. And if it's not *talking over one another* 

Tovah Feehan: oh sorry. 

Brianna Miluk: Yeah, I was just saying- *talking over one another* 

Tovah Feehan: on Wednesday at two and you're like, oh shit. Like I don't know what just happened there.

I need to think about that. I'm not sure. But then you don't think about it and then the next Wednesday comes and you're like, oh crap, what are we gonna do? That's not, I mean that happens, that's real life. But also, like how can we prevent that from happening? Cuz that's not really serving the patient best.

Brianna Miluk: Mm-hmm. 

Tovah Feehan: So, I don't, one thing that I really like to do is you do this actually. Where you post a case and you have to like, think about it. 

Brianna Miluk: Yeah. 

Tovah Feehan: I think that is such great practice for critical thinking. And there's tons of ones like that even for swallow studies. Like, what is it? Dys- Dysphagia Case Files or UC dysphagia or something like that?

Brianna Miluk: Yeah. I can't remember the, I can't remember. 

Tovah Feehan: Where you can like watch the MBS and you can try to figure out, and then you can read the captions and see what was actually going on and kind of like test yourself that way. In class, I always start lectures with a case study, like, okay, here's like a brief synopsis of this case, and then now we're gonna learn content to help you try to problem solve this. And now at the end of class, we're gonna circle back to that case and like. 

Brianna Miluk: Yeah. 

Tovah Feehan: Based on what you just learned like what, what components do you see that are challenging and what would you do in therapy? So that from the very beginning, it's not just about like memorization and knowledge, it's about application.

Brianna Miluk: Yeah. Mm-hmm no, for sure. And I think that's like that's something that I like care very much about is like not just providing information, but also like providing the reflection. Helping with like, okay, now how do we apply it? Like, okay, you read the article, but what does that mean? What does that mean for practice?

How does it apply like from a qualitative manner? Just because you have the stat doesn't mean it's going to carry over. And like also I think the difference between this is like a whole soapbox I could have, but the difference between statistical significance and clinical significance and recognizing like just because something showed to be statistically significant in a super formalized study, how significant is it to your clinical practice? I'm thinking about I know I briefly mentioned like the tube weaning kind of thing. Like- 

Tovah Feehan: Yeah. 

Brianna Miluk: Statistically like they weaned from their tube one day faster, but like clinically, how does this apply to me? And like does that approach really matter? Does that one day? 

Tovah Feehan: And functionally. 

Brianna Miluk: Yes. Make the functional *talking over one another* 

Tovah Feehan: the goals? Like going back to what you were saying about goals, like does it, like, does it really matter if they like, I don't know, there's always these like random numbers that we have to put in goals and it's like, what is this? Like how can we make this more meaningful for families?

Like how can we make this more functional for our patients? Because sometimes I read goals and it's, again, it's that autopilot like, let me check a box. Let me just, but it, yeah, we're not really measuring the progress of what that child actually. 

Brianna Miluk: Yeah, no, I think goal goals is a big one that we get into autopilot on, and I say we as in like, I am, I am part of this. I'm not speaking for Tovah, but like. 

Tovah Feehan: Oh no. Yeah, no. Yeah. 

Brianna Miluk: It's a big one that you can get into autopilot with because it's just like, oh, let me just like put something in there and then we'll just move on. But like recognizing like how we write those goals can, can affect therapy because sometimes you get stuck in the like, oh, I have to target this goal exactly like that, or I can't measure it when it might not necessarily be exactly what the client needs anymore.

Or written in a way that like, is like supportive of the, the functional skill you're trying to achieve. 

Tovah Feehan: Yeah. 

Brianna Miluk: And kinda honing in on that. Yeah. Yeah, for sure. Okay, so the last thing I would like to do is talking about a case and kind of walking through this process of taking a case and going through the process of like, how can you critically think through a lot of the different layers of it and sort of what that looks like.

All right, so we're gonna do the case now. We're gonna walk through a case, but here's kind of the catch. And I'm not gonna lie, my heart's a little beating fast cuz I'm a little nervous because Tovah is gonna present a case again, based on real events, but she's gonna change a lot of the identifying information.

So, you know, it's, it's not gonna be exactly the same, but I'm gonna blind react to it. So, I am going to just say how I think about this case initially. Like where would I consider going to start out? What are the things that I'm looking at? Because we're hoping that this kind of shows that like critical thinking can involve different layers of thinking and it's not always like black and white, the exact same.

I have no clue what this case is. I literally know nothing about it. So alright, Tovah, give me, gimme a history feeding status and. 

Tovah Feehan: Okay. I'm happy too, for, to, to react blind. Like you're not alone, so you can like throw it back at me. 

Brianna Miluk: Okay. Okay. Okay. We'll see. We'll see. 

Tovah Feehan: I mean, I'm gonna be nervous, but I’ll do it.

Brianna Miluk: I know. I'm like, I'm like, oh my gosh. I'm a little nervous about it, but like, you know what, let's just do it. I'm gonna take notes as you tell me this case so that I can keep up with it. Okay. 

Tovah Feehan: I think that's a great example of like how you're use your practice, your critical thinking. Like it's impossible to remember all this stuff.

Brianna Miluk: Yeah. First step, I'm gonna take notes. All right go ahead. 

Tovah Feehan: Okay. So Little man is three years old. He has a, a rare genetic mutation that causes neurodevelopmental disability, motor planning challenges globally, low muscle tone. He has eosinophilic esophagitis with the only trigger at this point dairy. Cow's milk. And he has a laryngeal cleft that required a prolaryn injection. So, it's just a filler to help fill that space when there's a cleft. Not for you Bri, but if anyone's listening and they don't know what a laryngeal cleft is. And what else can I say about him? Oh, this is really important. So right before I started seeing him, which has only been a couple months he started a trial drug that is supposed to like off brand, but supposed to improve, like help with muscle tone.

And so, prior to me meeting him, he used to drool a ton. He has pharyngeal phase dysphagia. He's on thickened liquid. Let's see, he's on moderately thick when I met him. And he also has a G-tube to help with his nutrition and hydration, and he has had trouble gaining weight. He eats very small volume and with the liquid being thickened I think that that also makes it less appealing and he doesn't take quit as much volume.

But he's not drooling anymore. So, when I met him at that first visit mealtime was very stressful. Parents actually felt like they couldn't watch him when he was eating because if they looked at him that he wouldn't wanna eat and he didn't wanna sit at the table.

He liked to walk around and eat. And I think that's like all the big information, but you can ask like, whatever I left out. 

Brianna Miluk: Alright. So here, here are some of my thoughts. However, I feel like I have a couple questions first. So that is definitely where my brain is initially going of like, Hmm, I think I need more information. Okay. So, does this child, are they followed by any other specialists or currently seeing any other therapies? 

Tovah Feehan: Yes. 

Brianna Miluk: Okay. Who? 

Tovah Feehan: So, they're followed by GI and allergy.

Brianna Miluk: Okay. 

Tovah Feehan: Followed by neurology. OT, speech. What else? 

Brianna Miluk: Do they receive PT? 

Tovah Feehan: Off and on. 

Brianna Miluk: Okay. Okay. And then any, like, do they see a dietician for tube management, or is that primarily with the GI? 

Tovah Feehan: Primarily with GI as part of like a team. 

Brianna Miluk: Okay. All right. Next question I have is when- when were they put on thickened liquids?

Like how long ago was this? When did this happen? And then I also am curious when they got their G-tube and like, kind of like what was the, what was the reason that that was put in initially? So, like, when did it happen? Like what was going on at that time? 

Tovah Feehan: G-tube happened at a year old. And what was your other question? 

Brianna Miluk: So why was the G-tube put in, like what was going on around that timeframe that said, I mean obviously we, we know there was probably like weight gain issues, but like did this, you know, happen when solids were starting or like what kind of triggered that?

And then my other question was when they were put on thickened liquids, when did that happen and like, why? Did they have an instrumental? How long have they been on thickened liquids for? 

Tovah Feehan: Mm-hmm. So, he has had supplemental tube feeding for his whole life. 

Brianna Miluk: Okay. 

Tovah Feehan: But he did get a G-tube placed early on. It probably was honestly in infancy. But I don't remember the exact age. 

Brianna Miluk: So, did they have like a nasogastric tube for a little while and then the G-tube was? Okay. Okay. 

Tovah Feehan: And then based on the results of, he's had multiple swallow studies, his most recent one was, I wanna say it was in, it was last year. A little less than a year ago. And that's when he was placed on the diet that he's on now. But he, he had been on thickened liquids up until that point. They were just modifying and updating it. 

Brianna Miluk: Okay. Okay. Okay. So was placed on moderately thickened liquids at that time but has always required some level of thickened liquids. Does that? 

Tovah Feehan: Yeah. Yeah. The interesting thing to me is that when I read his swallow study, his swallow he did aspirate thin liquid, but when it came to thickening, his swallow on paper looked the same regardless of how thick it was. But they did go pretty thick. 

Brianna Miluk: Hmm. Okay. So, on the swallow study, was there aspiration just at thin or was there aspiration at slightly? Mildly? There, there was all the way across. 

Tovah Feehan: There was aspiration at thin and slightly thick. 

Brianna Miluk: Okay. 

Tovah Feehan: And then I think based on the frequency of penetration with mildly thick, he was placed on moderately thick. 

Brianna Miluk: Okay. Okay. Okay. Okay. Another question that I have is with the, like, up to this point, obviously we're three years old at this point and we've been having feeding difficulties since infancy. 

Tovah Feehan: Mm-hmm.

Brianna Miluk: So, have they been through any other feeding therapies, and if so, like, did the caregiver give you any insight on like what had been done, what was working, what wasn't working? Like, any information on that? 

Tovah Feehan: Yeah, he, he's followed by different teams, but never had feeding therapy. 

Brianna Miluk: Okay. All right. That's so surprising to me. Okay. All right. So, I'm gonna give you some of my initial thoughts. 

Tovah Feehan: Okay. 

Brianna Miluk: So, excuse me. Initially what I'm thinking about is that I wanna get in touch with the rest of the child's team and just see what they've been doing, where they're at. You know, maybe I can't talk to all of them, but can the caregiver provide me like any records or testings that were done so that I can just, you know, have that kind of all up to date?

I would really like to know what OT is working on, especially since there is motor implications. And you had mentioned like global motor planning difficulties and low muscle tone. I'm just curious where we're at with that. Actually, that kind of brings up another question. What is the mobility status or the ambulatory status of this child?

Tovah Feehan: He's mobile, he is walking and I'll say his, his muscle tone did improve. He's not drooling anymore, and his muscle tone did improve with this drug trial. 

Brianna Miluk: I was gonna ask, did you feel like the medication was, was working okay? 

Tovah Feehan: I didn't know him before, but just based on parent. 

Brianna Miluk: Well, based on what parent report?

Tovah Feehan: Yeah. 

Brianna Miluk: Okay. Mm-hmm. Is the child on any other medications? 

Tovah Feehan: I don't think he is. Maybe reflux meds. 

Brianna Miluk: Okay. Okay. Reflux meds maybe. But not anything like there wasn't no seizure medications or. 

Tovah Feehan: No, no there's not any other medication. 

Brianna Miluk: Okay. Awesome. Okay. So that's very helpful because I'm thinking like positioning around mealtimes. I wanna make sure that we have safety from there.

From a sensory regulation standpoint, are there any like hyper or hypersensitivities across like any of the sensory domains? 

Tovah Feehan: He definitely has sensory preferences, but he is actually pretty open to like a variety of flavors and textures and I think a lot of, even the preferences that I see as I've gotten to know him more so come with him seeking the sensory input to help with the motor output versus like, you know. Yeah. Does that make sense? Yeah. 

Brianna Miluk: Yeah. No, that makes sense. Like kind of want stronger flavors or like bigger variation in temperature or texture, just so- 

Tovah Feehan: Yeah, yeah, yeah. 

Brianna Miluk: Track where it is in our mouth from a motor standpoint. Okay. Okay. 

Tovah Feehan: He will eat frozen chicken nuggets. 

Brianna Miluk: Oh my goodness. 

Tovah Feehan: Like I've never met anybody who eats frozen chicken nuggets and I thought it was so cool.

Brianna Miluk: That's awesome. Honestly, it kind of makes me think about like, we've normalized eating like cold pizza, like why can't we eat cold chicken. 

Tovah Feehan: Right. 

Brianna Miluk: I don't know. Precooked. It's fine. That's so funny. Okay, that was gonna be my other question was from a solid food sta- status, where, what is the child currently taking in?

I know you said like still having to supplement through the G-tube, but are we, I mean, frozen chicken nuggets now, but at the time of evaluation? 

Tovah Feehan: Yeah, just like a few bites, a few times a day. 

Brianna Miluk: Okay. 

Tovah Feehan: Was mostly where we were at, but a variety of different foods. Okay, okay. Yeah. Different food groups, different textures.

Brianna Miluk: Okay. From an oral motor standpoint, even though we weren't taking in a lot, did the childlike, I know you mentioned low tone early on, but like how are oral motor skills just like functionally with those foods? Were there any that were more difficult than others? 

Tovah Feehan: Yeah, I mean, I think the more advanced texture we get, it's tricky.

And you can see some reduced bolus formation, open mouth chewing but functional, maybe sometimes swallowing a little too soon, like before the food's all the way chewed up. And I think sometimes too, like you mentioned, reaching out to OT, so when it comes to self-feeding, because that motor planning piece is already challenged, if we're putting too many things, like too many. 

Brianna Miluk: Demands. 

Tovah Feehan: Challenging tasks for him. So yeah, so thinking about foods maybe that are easier to hold. So, if we're, if we're trying to promote those oral motor skills. Like working on one thing at a time, I guess. So even like working on cup drinking I needed to help him hold the cup so that he could focus on what his mouth was doing. 

Brianna Miluk: Mm-hmm.

Tovah Feehan: So, he didn't have that burden of like, how far should I tilt the cup and how far should- too many things. 

Brianna Miluk: Mm-hmm that's another thing I was gonna ask. You had mentioned that the child was on moderately thickened liquids, and so I was gonna ask how are they taking those in? It sounds like maybe open cup is the primary.

Tovah Feehan: Oh, so this is so interesting and you would definitely like geek out with me over this. So, when I met him, he was having it and I think this is how the team had recommended it. They were doing thickened liquids using purees. 

Brianna Miluk: Oh, okay. Yeah. 

Tovah Feehan: And so, at our second visit we IDDSI tested it and he had coughed a few times with it. And it turns out that you know, like purees can get waterlogged and also mixing, like it's really hard to mis- mix it. 

Brianna Miluk: Not all purees are created equal. That's usually what I say. 

Tovah Feehan: Yeah. So, when we syringe tested it, if you took up one syringe, it would've been considered mildly thick. If you took up another syringe, there was one that came out thin.

It was like very inconsistent. And so, we started using Simply Thick packets. So, well I can talk about what we're doing with thickening if you want. Or did you wanna talk about. 

Brianna Miluk: Hold on, let me make my. 

Tovah Feehan: Yeah, yeah. Make your prediction. 

Brianna Miluk: My guess. Yeah. This is like, I feel like we're playing 20 questions. I'm like, just answer yes or no. Like. 

Tovah Feehan: Well, you do, like in a visit I'd be asking parents all these questions. 

Brianna Miluk: So many questions. I have so many questions. Yeah, cuz I was gonna say, what are you thickening with? That was gonna be my next question. So, it's primarily purees. Okay. 

Tovah Feehan: But we changed to Simply Thick. 

Brianna Miluk: Okay. Yeah. Well, so part of like, my thinking about a child being on thickened liquids is the first thing I always do is test it with IDDSI and say, where is it actually at?

Tovah Feehan: Mm-hmm. 

Brianna Miluk: Because sometimes I find parents have been eyeballing it or they were given a recipe for something, but they're starting to use other things. And so, the recipe may not be perfect or might not be the same with every puree. So, if they've been using that with applesauce and then they started using something else like a yogurt or, you know, whatever else, or not, you know, in this case a non-dairy yogurt if they started thickening with something like that, then it might not come out the same.

So usually IDDSI testing is, is where I start out to just get that baseline. However, I'm thinking about like with this child, is it possible because they've never had any therapy to change their thickening- thickened status, to do some like systematic weaning off of thickener. But to get there, we have to have a consistent thickness.

And so, thinking about like, all right, like as much as you know, we, we wanna do some purees, I think we need something that's more consistent. And so, going to a commercial thickener can really help with that because we get them to a baseline status. It's the same. We can make all liquids the same no matter what they're drinking, and then we can wean it.

Because if we start weaning thickener and it's inconsistent, we're, you're totally defeating the purpose of what you're trying to achieve. So that's one thing I'm thinking about with the fact that the child's on thickener. So, you know, working on, and I also agree with, I know you kind of already hinted at this, but I agree with like, not doing too many things at once.

So, I actually talked about this with some people on my mentorship call this morning about when you're weaning thickener. If you have a child that is taking liquids currently right now from a sippy cup or from a straw cup, and you're like, oh, but we also wanna work on an open cup, it might not be the time to work on an open cup at the same time that you're doing that thickener weening because you're like throwing way too many things on them at once.

So, if you have a child on a sippy cup and you want them to drink from a straw cup, work on that skill, then wean the thickener, you know, then you can slowly reduce it. But if you're changing a motor pattern from an oral standpoint at the same time as the pharyngeal standpoint, sometimes that's just like cognitive overload and it, it can be really hard to really see changes there.

So, I think also recognizing that piece, but building on their independence with it. So, you didn't, I don't think you had said what cup specifically they were using for this. What were they? 

Tovah Feehan: Yeah, he does use a straw cup.

Brianna Miluk: Okay, cool. Cool. So, love that. I think though choosing straw cups that have things that can support their motor ability, so I always want to promote competence within the child.

So, like, I want the child to feel capable of what they're doing. So maybe that means we put handles on it depending on what he needs. Or maybe we use, like, I, I don't under overestimate or underestimate the power of like a bent straw, like one that has, I'm showing this on the video if you're listening, but like a straw that has a bend in it so that the child doesn't have to like put their head over the straw cause- 

Tovah Feehan: Right, right, right.

Brianna Miluk: That motor pattern can be trickier. So slight modifications to support their independence with a cup that they, they are capable of using. So that's kind of what I'm thinking about from a thickened liquid standpoint. Also, wanna make sure we're implementing oral care and honestly, like I would probably be doing some sterile water trials at the same time.

I'm a big water trial person. But it depends. It, it just depends on where they're at with it and if they can tolerate it. So, you know, if, if we are gonna do any water trials, then making sure it's, you know, sort of like a modified Frazier free water. So, I'm not gonna just like open end, like, you can have as much water as you want, just like single sips.

Cuz kids don't do that. We have to recognize that. But working on the motor pattern, we, we ultimately want to achieve. 

Tovah Feehan: Some grownups also don't do that. I just wanna say. 

Brianna Miluk: I know, I know grownups don't. 

Tovah Feehan: I don't follow the rules, so- 

Brianna Miluk: No, no. It's so hard to follow the rules. But so again, that's gonna be very family dependent.

I haven't met this patient or their family, so it will depend on. How I feel like if they can take it on, however, I would not do that until we have all these other pieces, like managed, until IDSSI is good to go, we're weaning the thickener. That's consistent, things are going well. Then I would consider adding that in.

Because like we, you know, if we wanna swallow thin liquids, let's practice swallowing thin liquids, but we can do so in a safe and therapeutic manner. From a, what was I gonna say? The solid food standpoint? I think, like I, first of all, I love working with patients who are not super res- like hesitant about certain textures or sensation like pieces.

It's like, oh, great, we can just like put whatever, however I think just like paying attention to the small volume pieces and like, why is that going on? I would probably want to reflect a little bit on their current like tube feed schedule. Because if they're filling up on formula through their tube feed, that might be playing a role in why they're only eating a little bit at a time.

However, if we play with that a little bit, you know, of course collaborating with the gastroenterologist on that schedule and recognizing like, okay, what do they need to take in? But if the gastroenterologist is like, you know, cool with us being a little flexible on it and we're still seeing very low volume intake, I'd wanna collaborate again with a GI and say like, is there something going on from an emptying standpoint where we only wanna take in a little bit of solids or, you know, whether that's at the esophageal or like the stomach level.

Either one, because liquids like formulas will digest faster than some of those solid foods. So, paying attention to that piece as well. All right. That's just kind of my like blind react initial. That's, that's where I'm stopping. I'm done, I think. I feel like I'm probably missing a hundred things, but you know what, that's where we're starting.

Cause it's an ongoing process. That's what I'm telling myself. Your ongoing assessment always. So. 

Tovah Feehan: Ongoing assessment. 

Brianna Miluk: Mm-hmm. 

Tovah Feehan: Yeah. I love it. You hit on so many things that were important. So, the first place that we started in therapy, and I should say like, it's only been a handful of sessions. Like this family is amazing, like so much smarter than me.

And, he's amazing. And he is also amazing. Like I am Mm. I'm in love with this little boy. But he okay, so the first thing that, that we really did was to um. And when we talk about the why, I wanna say too, and I know you are really good about this, like I'm ta- I'm thinking out loud with parents about like, here's why I'm suggesting something.

What do you think? How is this gonna work for you? What does the mealtime look for you like? That's so huge. Because I could say all the things, but if it's not gonna work for their life. It's like, who am I doing this for? So really talking about how to improve mealtime structure for him so that it wouldn't be so stressful for him and for his family.

And also, so it could be something where he's like, you talked about positioning, where he's like participating and comfortable. And that was that happened really quickly. Like from session one to session two. Mom was like engaging, sitting with him. They were like chatting and she had gotten this really cool footrest that I never saw that like inflates to like different heights.

So, freaking cool. And he loved it and he felt like nice and secure. And so even from the outset, like the, just that alone, just having like regular mealtime opportunities, not grazing, sitting with his family and eating in a comfortable supported position, he started to eat more volume. And so, then at our second visit we started to, he was throwing up with some of the bolus feeds.

And so actually, like I know you feel strongly about this, about like kind of like tube feeding on demand, right? So, we talked about how like actually the biggest risks for aspiration pneumonia are aspirating your dirty saliva are aspirating puke. So, and so if we think about that and we think about how like his tone is improved and he is not drooling anymore, but he's still throwing up.

So, they started to reduce that last bolus feed that he was always throwing up anyways. And we also started to do a thickener wean. And if we talk about implementation science, we were using the research out of Boston and using that systematic thickener wean. So, we were adding an ounce of thin liquid and keeping the thickener the same.

And I know there's different ways you can do it, that's just what was the easiest for the family and what would like fit in his cup and I think honestly it's probably thicker than what he was having before when it was mixed with the puree. So, we're trying to like navigate that now. But we started the thickener ween and then when they started reducing that last tube feed of the day from that visit to the next visit, and there were two weeks in between each of these he started eating a lot more volume.

It's the first time that he had like a big jump in weight gain. And so, we had one more visit and then we met with the dietician this morning actually like as a team. And they're going to be switching over like from a hydration perspective. He still needs the support from his tube. And we're hoping that as we wean the thickener, it becomes more appealing for him to drink more.

But for now, we're gonna swap out at least the calories for that so that he can eat more volume and rely less on it from a nutrition perspective. Yeah. 

Brianna Miluk: Awesome. Yeah. I love it. Yeah, I feel like I appreciate that you shed more light on than I think I did justice for just like mealtime routine and environment and like that aspect of it and how important just like that can be.

I feel like I was talking definitely more from the like tube feed routine and mealtime like schedule, but also recognizing like, not just the schedule, but like what happens at the meal. Like, who is doing what, what is, what does that look like? Is is another part to reflect on for sure. So. 

Tovah Feehan: Yeah, and it's all really important.

Brianna Miluk: Yeah, that was a good one. I like that. Okay. Do you want one? 

Tovah Feehan: Yeah, get me.

Brianna Miluk: Okay. All right. Hold on. Let me think. 

Tovah Feehan: Because I'm uncomfortable so I have to do it. And it's okay if I'm wrong. It's okay. 

Brianna Miluk: It is. All right. It's your turn. Tovah. Okay. So. 

Tovah Feehan: It's like I'm on a game show. 

Brianna Miluk: Yeah. Yeah. Right. Okay. Blind react to this one. And just so everybody knows, like literally this is on the fly, like I just had to think about a case and put it together. All right. So, this is an infant, two months old and was born full term, but has a diagnosis of Trisomy 21 is on a G-tube and is getting feeds through the G-tube for like, they're, they're dependent on that.

However, caregiver is pumping and then they are getting breast milk and then supplementing some of the feeds with formula for weight gain. So, infants having some difficulty with weight. Caregiver really, really wants to breastfeed. Highly motivated to breastfeed. Right now, they are trying it like once a day and mom just reported like, just doesn't really latch ever.

And if she does latch it's for like a minute, or not even a minute, like a moment and then just is kind of done. And so, she's attempting once a day, but that's kind of as far as they, they've gotten with it. But she's very motivated. They have not tried a bottle at all at this point. They did try for a little bit.

The gastroenterologist kind of had them take away some of the tube feeds to see if, like, maybe she just wasn't latching, cuz she wasn't hungry. However, you know, she showed signs of hunger and was hungry, but could not get milk from the breast. And so, started losing weight again. And so, they put the, the tube feeds back up.

So, there you go. That's what I have for you. What thoughts and questions do you have? 

Tovah Feehan: How, how old is the baby now? 

Brianna Miluk: Two months old. 

Tovah Feehan: Two months old. Okay. 

Brianna Miluk: Eight weeks. Like, like fresh two months, eight week. 

Tovah Feehan: Fresh. Fresh babe. And cardiac involvement? 

Brianna Miluk: No, actually we do not have cardiac involvement. Good question though. 

Tovah Feehan: So why did she get a G-tube right away? 

Brianna Miluk: Difficulty with feeds was on the NG tube feeds. They attempted breastfeeding early on. It wasn't going well. And so, they just. 

Tovah Feehan: They never tried a bottle? 

Brianna Miluk: They tried, but it also didn't go well. And so, they, yeah, this was a case where like, again, you know, maybe, maybe did we need the G-tube?

Maybe we could have stuck with NG a little longer and gotten support, but no, they put a G-tube in before they left the hospital. 

Tovah Feehan: And no other comorbidities like respiratory? 

Brianna Miluk: Mm-mm. No. 

Tovah Feehan: That's very unusual. 

Brianna Miluk: Yeah. Yeah. 

Tovah Feehan: Feeding difficulties were that the baby would just wouldn't take in having trouble latching and not taking in the volume.

Brianna Miluk: Yep. Yep. Very, very weak suck. Would suck, but very weak. Like just- 

Tovah Feehan: Yeah. 

Brianna Miluk: Frequent unlatch, difficulty maintaining latch, and yeah. 

Tovah Feehan: So, no pharyngeal like diagnosed pharyngeal dysphagia? 

Brianna Miluk: No. 

Tovah Feehan: Okay. Yeah. So. Many things that I would wanna, like, see or try mm-hmm. Like, I guess seeing why it's tr- why is it hard for the baby to latch?

Like is it purely that low muscle tone or is it, is she dysregulated? Does she need to be like swaddled? Does she need rhythmic music or movement? Does she need that piece of it? Does she, is she spending a lot of time in skin to skin? And then thinking about like, trying the bottle and seeing what that looks like for her.

So, will she take the bottle? And, but like she can't get anything out. 

Brianna Miluk: Yeah. So very discoordinated. Like even with the slowest flow nipple. 

Tovah Feehan: Yeah. 

Brianna Miluk: Just like spillage everywhere. So, like, not really working with the breast. Like when she would latch, it was like okay. 

Tovah Feehan: All right. 

Brianna Miluk: So, like we couldn't. 

Tovah Feehan: But it was more so she couldn't get any liquid out.

Brianna Miluk: Yeah. So, but like, just very, very weak. And then frequent unlatching and mom's milk supply too, like milk supply was good. Milk supply. 

Tovah Feehan: Okay. 

Brianna Miluk: She was doing really well with that and keeping up with, with pumping in- 

Tovah Feehan: That's awesome. That's so much work. 

Brianna Miluk: So much work. Yeah. This mom was a Rockstar for sure.

Tovah Feehan: Will the baby take a pacifier? 

Brianna Miluk: A little bit. She'll, again, kind of just like short duration, but if you try to like, tug on it at all, like very quick release, like very, very weak, weak suck. 

Tovah Feehan: Yeah. And is she on like with her tube feeding schedule, is it continuous bolus? Pump? 

Brianna Miluk: It is bolus and it's very consistently every three hours, even overnight.

Tovah Feehan: Okay. 

Brianna Miluk: Mm-hmm. 

Tovah Feehan: Yeah. 

Brianna Miluk: Oh, sorry. Overnight was continuous. I meant like consistent hours during the day. Overnight they would get a continuous feed and I apologize, it's been a while, but I wanna say it was like over six or eight hours that the kind of overnight part was. 

Tovah Feehan: And is the baby showing hunger cues?

Brianna Miluk: So, when they did the, not really right now in, in that schedule, but when they tried to wean some of the tube feeds, she was showing hunger cues and was hungry, however, couldn't actually like get the milk to support. 

Tovah Feehan: And neurological reflexes intact? 

Brianna Miluk: Yeah. Is being seen by OT and PT as well. Developmentally like we, we have global developmental delay and you know, low tone, but otherwise, yeah.

Tovah Feehan: Yeah. So, I'd be curious you know, if we get her in that calm alert state, she's regulated and it's just before a tube feed and we do some skin to skin and maybe try a supplemental nursing system to help, since her challenge is the extraction piece. So, if we can help her with that and she can also have that experience, I'd be curious to see how she'd do with that.

Brianna Miluk: Yeah. Okay. You wanna know kind of. 

Tovah Feehan: Yes. 

Brianna Miluk: Okay. No, you're like, you're like, is very, very similar in, in thinking about how I was going through this. So, one my brain first went into, we've only been practicing breastfeeding one time a day? That's not enough opportunities for us to kind of learn this skill, but again, mom just hadn't received guidance on anything else.

So, she didn't know. She's like, we try it once a day, it's not going great, but, you know. 

Tovah Feehan: Right. 

Brianna Miluk: That's just where we're at. So, one of the first things was just more frequently. So, like you said, like before every tube feed and I told her, I said, we want quality over length of time. So, like, if you put her to the breast and for one or two minutes, it's going very, very well.

Great. If she shows like, okay, I think I'm done, then just stop. We wanna keep it positive, keep that experience. However, before each of those, we talked a lot about increasing skin to skin, supporting that regulation piece. If she's fussy and moving and not, you know, all over the place. We're not gonna force into the breast.

So, we talked a lot about, a lot about that piece and honestly like between that and doing some positioning change. So, we ended up because of, you know, that that lower tone that we're kind of working against, we talked about like, okay, let's, let's try to make this a little bit, little bit easier for her.

So, we did like a reclined sideline position, so sideline, but also had mom lean back just a little bit. And once we increased that frequency in practice and supported that, like reading the cues early, supporting that, like, so if we think, you know, again, implementation science, if we think about motor learning principles and neuroplasticity, like frequency repetition, is a big part of it.

And she was able to wean off the tube and exclusively breastfeed. 

Tovah Feehan: Oh. 

Brianna Miluk: So yeah, it was like, ugh. It was so exci- it was so amazing. But I will say, I attribute this. 95% of this to mom's dedication and commitment to that. Because she was so motivated to, to work on that. And we had talked about, you know, like, okay, like, you know, we might introduce a bottle, we might try SNS, like let's see how it goes.

But the first approach was definitely like, let's just support her regulation. Let's read those cues and let's get enough practice. Cuz right now, like her endurance, right? So, she had like the range of motion in terms of like, she can latch and she can hold on for a moment, but her endurance wasn't there.

And the strength wasn't there to be able to like extract and do that over time. And so over time she, she was able to build that skill and it was like, awesome. And then eventually we, we progressed into doing the bottle then, and it was very similar in. Okay, here is the bottle. She's a little discoordinated, but guess what?

She just started trying it. So, like, let's give her a little bit of time and kind of supporting that piece as well. And then same thing with solids. And then she, like by a year old, she was just like on her way doing her thing. 

Tovah Feehan: I love that so much. And it, it just, it highlights the fact that in both of the cases we talked about, we didn't explicitly say this, but a huge part of the therapeutic process was partnering with the parent and really like troubleshooting with them because like in my situation, like I can tell you what's ideal for positioning, but this mom was like, you explained it to me.

I know why he needs this and I'm gonna find the right one that he'll like. And it wasn't one that I had ever seen before. 

Brianna Miluk: Right. Or like the one that works for like our space and our kitchen. 

Tovah Feehan: True. Yeah. And also, the other piece of it is like by including the parent, you also like empower them and you help build their confidence as a parent.

So, like this mom felt like I can do this multiple times a day, and it's okay. It might take a little while. And this is, she's telling me like, I know now she's telling me that she's done or she's telling me that she needs a little help or whatever it is. And like that is like, that's where the magic happens.

It's so awesome. 

Brianna Miluk: It so is. And like I feel like in both cases too, like having the focal point of the family and connection. 

Tovah Feehan: Yeah. 

Brianna Miluk: With that child both had to happen in different aspects, but like that you like will not go wrong if you focus on attachment and, and supporting that. 

Tovah Feehan: Yeah. 

Brianna Miluk: And then you can figure out all the other things, but like that, yeah, that should be, should be a primary.

So, yeah. Oh, so fun. Those are good. Those are good to talk through. And of course all of these have like different nuances and little bits that we did not go through, but like when you're thinking initially where your brain goes, and both of us both could draw on research and like what the empirical data shows in certain situations to help justify those decisions and making sure that like, critical thinking can help during sessions if you critically think it through with the family.

So, include the family in it, help them understand the why. Like you were saying, Tovah like almost like narrating your thought process. So, I wanna try this because of X, Y, Z. And it's like, as silly as it sounds like that's, that's critical thinking in the moment because then the family can provide you feedback on- 

Tovah Feehan: Yeah, I have learned, like some families, like I need to like dial it back a little bit because I don't wanna overwhelm people with all of my thoughts.

So sometimes I'm like, I'm just gonna be quiet for a second and like think about this. So yeah, even that like critically thinking like, what does this family need right now? Like how much can they handle me recommending or hearing or you know, even asking about history, thinking about like potentially triggering trauma like past traumatic events.

There's so much critical thinking that goes even to just navigating that relationship. 

Brianna Miluk: Yeah. And how you ask a question and open that up and yeah. I think that's where like, you know, the, the open-endedness of stuff can be, can be so helpful. And, you know, in a conversation I had with another colleague and talking about like, you know, asking questions like what would, like, when we're talking about like parent coaching, like what would maybe happen if you did this or like how do you think that you could support your child in, you know, and being very just like open-ended in it.

Like, Hmm, I wonder what would happen if we tried this position. What do you, what do you think about that? And like, helping parents to really like guide the therapy. 

Tovah Feehan: And also, like having it come from an authentic place because for real though, parents are the experts in their kids and they're gonna know stuff that we would just never know.

So, for real, like, it's not like when you say that it's, it's, we do want them to feel empowered and involved, but it's also genuinely like, help me understand your child better. Like what motivates them and. 

Brianna Miluk: Yeah. I always tell families, I'm like, everything that I say is a suggestion and if it doesn't work for you, I also need you to tell me that.

Cuz like, let me tell you, I am chuck full of suggestions. I have got, I could come up with anything, but it does not matter what I say to you if it doesn't work for you. And being able to navigate that because every single situation is different and like that that, yeah. That I'm like literally be like, yo, Bri, cool.

Thank you so much for that. Not gonna work for me. And it's like, great, now I can come up with something else that will work for you and we can generate that together. Cuz if you don't give me that feedback and you're like, yeah, thank you, cool. We're gonna do that, and then it doesn't work. 

Tovah Feehan: Mm-hmm. 

Brianna Miluk: You don't do it because it's not gonna work for you.

We're not helping each other. And so also like opening that conversation up too. 

Yeah. Yeah. 

Tovah Feehan: Or maybe it's like too stressful for a parent. Like it might be like a good move theoretically. Like, say it was like tube weaning and maybe like 20% for them is gonna make them super stressed out. It's not worth it.

Like, we can go slower, we can do 10%. Like this wouldn't be my call. This would be, you know, working with the medical team and the dietician, but just using that as an example of like, you know, it's not just about like the quote unquote right decision. It has to be the right decision for them. 

Brianna Miluk: Mm-hmm. Yeah, for sure.

Because yeah, there's, there's so many different approaches to it. So, or even like you're like, you know, I think we're, we're ready to start, you know, weaning this thickener, but if the family just does not quite have a hold on, how to do IDDSI testing or they don't feel totally comfortable with like, what we're working on yet.

Like that's what we have to support first. It's not that this approach or this therapy or this recommendation will never apply, it's just that maybe that doesn't apply right now. That's not what they need in this moment. And so, it's not that like, oh, that's never gonna happen. It's just you might have to circle back when, when other things have been managed.

So, but yeah, that involves a lot of critical thinking to get there. 

Tovah Feehan: I'm massaging my brain right now. 

Brianna Miluk: My brain hurts from this episode. 

Tovah Feehan: My brain hurts but like in a really good way when you go to the gym, which I never do and I really should. But if I went to the gym and then you're sore the next day and you like, feel good about soreness, like that's how my brain is right now.

Brianna Miluk: Yes. That blind react was so fun. That was fun.

Tovah Feehan: It is fun. It's so helpful. And it's also, I feel like you can always, as a clinician, I'll get like imposter syndrome. I'll feel like a fraud. I'll feel like, ooh, if only I was like this person. And so, it's again, if I like stay in my own head, it's very dangerous.

Brianna Miluk: Yeah. 

Tovah Feehan: But if I'm talking with people like you and being like, okay, like, so you would've done the same thing too. Okay. Or like, that makes sense why you would've done it a little differently. I should try that. 

Brianna Miluk: Mm-hmm. 

Tovah Feehan: But I'm not like stuck in my head like. 

Brianna Miluk: Right. Mm-hmm. 

Tovah Feehan: It's a dangerous place. 

Brianna Miluk: Yeah. Yeah, yeah.

My head is very dangerous. Do not recommend going in there okay. Well, Tovah, thank you so much. I'm so excited for these to go out. I like, I'm just so excited. Is there anything else you feel like we didn't cover or that you want to leave as just like a final mic drop on critical thinking? 

Tovah Feehan: No 

Brianna Miluk: Perfect.

I feel like we literally covered so many aspects of critical thinking on, you know, I, I feel like my, my biggest point or the biggest thing to take away hopefully for everyone is that like, this is an ongoing process. 

Tovah Feehan: Yeah. 

Brianna Miluk: It's not, you go from not being a critical thinker to being a critical. It's gonna ebb and flow.

This is, this is a journey. And once you start progressing on that journey, like it, there's gonna be times that are harder than others. There's gonna be challenges, there's gonna be uncomfortable moments, but like as long as you are actively engaging and recognizing like, Ooh, I need to think a little harder about this, or I need to slow down to think about this, while on your way.

So, cool. Thank you so much, Tovah. I appreciate you. 

Tovah Feehan: I appreciate you so much. 

Brianna Miluk: Thanks for tuning in to the Feeding Pod this week. If you enjoy 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 @pediatricfeedingslp, or check out my website where you can get access to more courses and information,

Again, thanks for being here and listening to my ramblings, and I hope you'll keep listening. Until next time, cheers.

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