Functional Oral Motor Examination


Bri: 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.

Bri: Welcome back to the feeding pod, I'm Bri, and today I am accompanied by Dr. Katherine Sanchez. And if you haven't listened to her 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 mech exam.

When we're thinking about oral motor skills with pediatrics, we all know this can be a little bit tough to approach with some of our little ones. Before we start and dive into this though, Dr. Sanchez, why don't you give a quick introduction? 

Katherine: So, I did my PhD a few years ago on oral 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 functional 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.

Uh, and I'm also the pediatric medical editor for The Informed SLP. 

Bri: Awesome. Well, those are obviously one of the reasons I brought you on was because you have studied oral motor skills in pediatrics so extensively. I think you just can shed a lot of light on 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, starting out, what are some of the first things we should think about when we are completing an oral motor? 

Katherine: I mean the oral motor exam starts the second you see the child really because straight away you're looking at some of their facial features and facial structures looking for symmetry, doing some of that real basic 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 you know 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.

We need to think about it as starting really from the second 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 they don't like it. So, do all the fun stuff first and then do the exam of the inside of their mouth after that.

Looking at the tongue, looking at teeth, looking at palate and velar function. We've talked a lot about how we always want to 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 we're going to dive into a bit more today. 

Bri: Yes. Yeah, definitely. I think you made a good point of 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 walk over, try to get into their mouth, the whole rest of the evaluation's going to be tough. It's going to be hard to build that rapport. And I honestly can say that I have had some kids that it is not going to happen and I'm not going to push it and we'll figure it out later, and that's why talking about this oral motor exam in 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. 

Katherine: Absolutely. 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, in my clinical notes that I need to get a look in their mouth in the second session or the third session. And the other thing is making sure that you're being opportunistic.

So, if they're having a big belly laugh or, if they start crying, then that might be your opportunity to have a really good look in their mouths without having to do a purposeful task where you, you know, have to try and pry their mouth open. 

Bri: Yes. No, I completely agree. I think, like you mentioned with being opportunistic, 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. I think they call it like the Guppy where a child leans way far back and you're like, oh, and you can do like peek-a-boo 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?

Katherine: It definitely depends on the age of the child. Some of those opportunistic methods and, getting the child leaning back on their parent's lap work really well for the little kids, little infants. For the older children, it's not always quite - Mirrors can be really helpful if you've got a nice big mirror that you can sit in front of together, that can be really fun. And then you can just, you know, we're doing crocodile mouths or we're doing a big roar, like a lion. And, oh my goodness. I can see your tongue can say all the way back into your mouth and make it fun like that. 

I saw a wonderful post on Instagram about using phone filters. To get oral motor exams going, so getting your phone or your iPad out and using some of the filters that changed the way a child's mouth looks. Then you're actually doing the examination. 

Bri: I'm sure a lot of older children really like to do that.

Katherine: Yeah like three, four-year-olds.

Bri: Yup! 

Katherine: I think that's super fun and just makes it a little bit less clinical and a little bit more sort of gamified. Cause they can make their mouth do all different things and suddenly all of your oral motor tasks 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 where she's 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 mom. 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'm always keen to extra tips on how to do, oral motor exams.

Bri: No, all of those are really great. A lot of times because I mostly see under three I'm doing a lot of playful games. I noticed 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've already been able to observe. I find that that helps as well, because a lot of times, by the time. I am hoping to look in their mouth. It's usually an assessment, of structure, than actually how it's functioning. 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. 

Katherine: Mm. Yeah, I completely agree. I think eating drinking you get so much good information from that part of the assessment and my most intensive experience doing oral motor, anything was scoring, um, a little over 200 SOMAs, which the SOMA is the Schedule for Oral Motor Assessment, which is a standardized 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 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 inter-rater reliability. It is really amazing how much information you can get just from watching a child eat and drink.

Bri: Yeah. I agree. But then there's always that case of the child doesn't want to eat or drink in front of you because now, when we think again about rapport, you have that kid, that's like, I don't want to do anything. One of the first things I'll try just to see if they will is I'll be like, "I'll be right back. I'm gonna go get a cup of water or I'm going to go to the restroom or," I say something, and I tell the parents like, "go ahead and get started." And I'll leave for a couple minutes. And hopefully when I come back, the child's a little more comfortable. They're having fun eating with their caregiver, and I can do some observations while I'm still kind of acting like I'm not paying attention to them. I'll usually try that first, but what's another strategy you might use if a child is just not willing to eat at all? 

Katherine: I look at a lot of videos on parents' phones. And I think this has definitely increased in the last 18 months - 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. Um, also most parents have videos of their kids eating on their phone. So even if you haven't pre-prepared 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.

Cause 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. But 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.

Bri: Yeah, I agree. I love watching those videos. Sometimes it can tell us a little bit, about the psychosocial side of mealtimes as well of like, how did they respond if they're like, oh, this was a meal that was difficult, and the child gagged. What did their 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 a child's oral motor skills to really be able to say, what's going on. So, moving on, we understand oral motor 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 is this kind of moving toward? Because I always differentiate between an oral motor exam and a functional oral motor exam. 

Katherine: Yeah. 

Bri: Ultimately we should be doing that together. 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 mech exam.

Okay. Smile, pucker, tongue out, put your tongue up, put your tongue, 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. 

Katherine: Yeah, often when you're doing an oral mech exam, I feel like the purpose is about ruling things out. Wanting to rule out a cleft palate or wanting to rule out any sort of neurological issue that you may have previously been unaware of 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 where we notice where the child is struggling 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 phonemic inventories can be really helpful for some of these older kids as well, because I think, you know, I'm going to share a case study a little bit later where the phonemic inventory was a really interesting part of 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 out about eating and drinking when we're looking at - at a child's eating and drinking. So yeah, I guess for me the functional end of the oral motor exam, 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 oral mech 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 completely reliable or derive from a huge population of children and confirmed many times in many different contexts they're 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 we also need to acknowledge that when we're looking at some of these oral mechanical functional exams, our interpretation is going to be subjective and that means that one of the best things that we can do to make our examinations more reliable is to just watch a lot of kids eating and looking in kids' mouths and like -

Bri: I like literally just the other day I was on a call and was like, have y'all ever just sat at a daycare and watched kids eat, like, just watch lunchtime at a daycare. You could be sitting there and none of the kids have feeding issues. Like it's okay. But you just watch them eat. And it is so interesting to get that picture of the range of normal.

Cause there is 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, functional norms for oral motor skills, because the range is huge. 

Katherine: Yeah, absolutely. Anterior spillage everywhere.

Bri: Oh yeah. And some of the kids are taking huge bites. Some of the kids are picking and doing little tiny bites. Just looking at it as a whole. You're like, what is going on? 

Katherine: I was talking to someone recently who has seen a client that I see as well. This child is eight months old, I think, and for various reasons started quite late on solids. She's got quite a complex background and has now started taking sips 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 fluoro to look for aspiration. And I was like, look at a typical eight-month-old with an open top and almost all of them cough. Which is not saying that we shouldn't watch the clock and look for whether it's consistent and look for when it happens and whether they can clear it and all of those things. But yeah, typically developing, you know, 6, 8, 9, 10-month-olds with an open cup will cough a lot. 

Bri: Yeah, if we even think from the oral phase, just trying to manage that, 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, child that just has motor limitations is trying to independently drink from that open cup, that can provide a level of difficulty as well. 

Katherine: Yeah, absolutely. And unless you go out and watch a whole bunch of typically developing children, eating, you don't realize maybe that that is happening, and you think back to your adult placements where bedside coughs were turning on that radar for looking for danger signs.

So yeah, as you say, sitting at a daycare and watching a kid eat, or, you know, you played in the kids play group or your nieces and nephews or whoever can be just really powerful for figuring out what looks normal. 

Bri: Yeah.

Katherine: "Normal." 

Bri: I know. Cause it's a big range. It's a very big range. You'll see one three-year-old eating and then another three-year-old and it could look totally different but going back to that functional side. So, 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.

Katherine: Absolutely. And in terms of judging those behaviors and whether they're functional, I think in terms of effectiveness, efficiency and acceptability, I think those are three really key things to think about. So, if their oral motor behavior is effective, (i.e. They can effectively, chew up the texture that 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, obviously for older children, what's acceptable among their peers is going to be different to the younger children what's acceptable. And then I think it's functional 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 first season in one of your episodes about function and oral motor behaviors and I just thought that that was a wonderful episode because 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.

A good example of this is tongue thrust, tongue thrust swallowing a lot of people if they see a tongue thrust swallow will get really concerned. But we have some studies that show that, you know, 40 to 60% of children have a tongue thrust swallow. And if it's a tongue thrust swallow that is not interfering with function then is it something that we as speech pathologists need to work on? A question that is good to ask ourselves. 

Bri: Yeah, definitely. And I think, 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 we're making about how a child should function, it's at a very high risk of bias of what we feel is functional. We have to be really careful about that, and really think of the whole picture and, 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 language pathologists need to be addressing or does that bridge over into another professional who may or may not be taking over on that. 

Katherine: Absolutely. I've certainly seen kids where a tongue thrust swallow pattern has not been functional. A three-year-old I saw who had a brain malformation and she had this really strong tongue thrust swallow that was pushing about three quarters of every bolus out of 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 sideways spoon technique worked. 

Bri: Yes, love when that trick works. 

Katherine: So we got to the point where she wasn't extruding too much of the bolus, and I was working in an acute setting, in a consultative setting where I wasn't able to follow her up therapeutically a lot, but 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 orally 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 the other professionals whose scope of practice that falls within might be able to address that if needed.

Bri: Mhm. Yeah. I completely agree. I think that's where the functional assessment becomes really important because we're actually looking at how is it impacting them? Is it affecting their nutritional intake? Is it affecting their 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, on like a straw or an open cup or something and I really think part of it was like, stabilizing and 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 and there was a very thin puree, you would see it, but on chewable solids, it wasn't really there, which was interesting. But from a functional standpoint, it wasn't affecting our ability to orally intake what we needed to. 

Katherine: Absolutely. That makes me wonder as well about whether that child might've been doing some tongue pumping to initiate a swallow on liquids because she wasn't getting sensory input. And whether

Bri: Yeah. 

Katherine: then the intervention is about the sensory input rather than the tongue thrust. It's not that we should address the behavior it's that we'd need to address the underlying reason for that.

Bri: Yes. I'm so glad you brought up that point because I took a note over on the side while we were talking cause 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, 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 lingual lateralization. Whatever it is that we see that's going on. We then have to take that information and say, okay, what are the possible whys that this is occurring? Because I think that also plays a big role in establishing a plan of care. 

Katherine: Absolutely. I had a little girl who I started saying last year. And she was having real issues with tongue lateralization - she was 10 months - really significant. Initially I thought, well, maybe this is an opportunity thing.

Cause she'd had significant weight issues. And so, parents were using a lot of purees because they just wanted to get the calories. And so, we did a couple of sessions where we talked about introducing some other appropriate foods that would 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 and I talked to the ENT and the ENT said, no, not a tongue tie, but I think this child needs a genetic assessment. 

Bri: I was about to go neuro. 

Katherine: Yep. Absolutely. Because 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.

Bri: Wow. 

Katherine: And that led to us finding out that there were some OT issues that needed to be addressed, that we need to work on communication as well. That she was slightly behind with her gross motor milestones, but now she's doing physio, because we're expecting that to continue. It's always interesting to dig around a little bit and figure out what the underlying issue is. 

Bri: Definitely, I do find oftentimes, like you mentioned that it is that lack of opportunity, opportunity to start. That's usually where I start let's look at what is the child consuming right now?

What does the history look like? 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, oftentimes, as you even 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? 

Katherine: Yeah, absolutely. And I think sometimes, in those children where there is more of an underlying why, whether it's a neuro type thing or whether it's more of a delay, just a delay. I think over offering opportunities can sometimes be an issue as well.

Like if the parents have said, all right, well, I'm going to do baby led weaning with my six-month-old. And then this is not a child that is appropriate for baby led weaning. Sometimes we can see oral motor issues emerge there because they have had opportunities, but they were not at the point where they could really take advantage of those opportunities. They just weren't ready to learn those skills yet. 

Bri: Yeah, definitely. I think that kind of goes into that range of normal as well. When we're thinking about, no, we don't have concrete normative data, but even if we're thinking about a bell curve and what that looks like, there are children that are going to 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, maybe that vertical pattern hangs on a little bit longer. And we do have a tongue thrust and tongue protrusion longer than we would, you know, "typically" see, and I'm using quotations. We don't really know what's typical, we have to think about that range where, 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.

Katherine: Absolutely. Yeah. And its really hard nuanced work to work out what your child is ready for. Parents aren't trained for 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, didn't have kids in my family, I 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?" now, you know, with a few more years under my belt, I'm like no some eight-month-olds are totally fine with orange and all of those fibrous textures, but I just saw so many kids who were not ready.

 A lot of them, didn't have known underlying issues. They were just on, as you say, the lower end of the bell curve in terms of oral motor skills and they just needed a little bit more tailoring with the foods that were offered to them. 

Bri: Yeah, definitely. It's funny you say that. Cause I feel like for a lot of parents, unfortunately, the like marketing of foods and how they're presented the different levels of baby foods just really do not relate to the skills we are seeing in these children.

And so, I think oftentimes that can be scary. I've had parents tell me well, we didn't start any chewable solids, cause they don't have teeth. They're like, I didn't think they'd be able to do anything cause 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, as you mentioned, don't have another developmental disorder going on that's causing these issues. 

Katherine: Absolutely. Yeah. The marketing of baby foods just goes so quickly to a mixed texture where they have to lump sort. And this is one of the resources I find most helpful from the SOS program is their texture transition sort of sequence with the dissolvables in there as a bridging food. That's the closest thing I can get to a magic wand in feeding therapy that takes to transition the children who just need something before they go to that lump sorting texture. Yeah, it can be really powerful. 

Bri: Yeah. It's a pretty big jump to go from the smooth to the lumps. 

Katherine: It is. But yeah, so many kids just do it without any worries, but out of the vulnerable people. I think they're more likely to have trouble with that. 

Bri: It's funny you 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 they maybe haven't had much of any foods or they're only doing very smooth purees 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. I oftentimes find as well that just going straight to the real soft solids can make a big difference as well.

Because once you get over 12 months, there's that level of like, can we build on this child's independence a little, would they just prefer to have a whole chunk of banana to, 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 you know? 

Katherine: Absolutely. No, I think that independence could be a huge and not necessarily, always over 12 months either, you get under 12 months who just do not like being spoonfed, very independent little spirits. Yeah, you can see big changes when you just start offering appropriate finger food that they can self-feed. This is a thing where I'm constantly getting ideas from social media about how to make foods more finger-feed-able, like using the crinkle cutters, and, sprinkle a bit of baby cereal on the outside of the avocado, so it's easier to pick up, but yeah, there's some great ideas out there. 

Bri: No, definitely. Any other thoughts before we go into some of our case examples of when we're thinking about oral motor skills?

Katherine: I don't think there's anything in particular that I wanted to say, it's useful just to mention that there are a couple of tools out there for oral motor assessments. So, I mentioned the SOMA, sadly, that is no longer commercially available. Maybe one day somebody will re-develop it.

Justine Joan Sheppard's DDS tool - dysphagia disorders survey was not available for a few years after she passed away, but it's just become available again. You can now do online training to get trained up in applying her scoring system for oral motor. There's the CHOMPS from the feeding flock research group.

If you do applications for funding, I think it's good to be aware of that EDACS as well, which is like the GMFCS, but for eating and drinking. So, the GMFCS, where you write gross motor function as a way of quantifying how severe cerebral palsy is in a child EDACS have a similar thing where I think it's a five-point scale. And you can quantify how severe oral motor feeding difficulties/dysphagia are in a child. So, some of those sorts of things can just be helpful to know about in case you need scores for insurance or other types of funding. 

Bri: Definitely. 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.

Katherine: They do! The CHOMPS questionnaire that's a pretty straightforward one if you're needing to apply. And it's free. You just have to Google Feeding Flock. 

Bri: Yeah, Feeding Flock is a great resource for all assessment tools, they're great. 

Katherine: Very generous. And yeah, some really nice tools that can give you data that's really useful for funding. 

Bri: Agreed. All right. Well, do you want to do your case first?

Katherine: This case was just so interesting to me. So, this was a little three-year-old boy. And he was referred to me by his speech pathologist. So sometimes I do second opinion consults where speech pathologists working out in the community will say, I've got this kid, I'm really confused. Or I just needed another pair of eyes to make sure that I'm on the right track or some ideas or whatever.

And so, I'll see they're signed for one session or a couple of sessions and then liaise back with them about the plan. So, this was going to 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.

 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 were common developmental conditions at play. So, she didn't feel like he was presenting in a way that was consistent with the autism or in a way that was consistent with global developmental delay.

So, she's really confused, and she thought, is there something oral myofunctional 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 history with mom. He had had major, major newborn feeding issues.

So, had been hospitalized twice for failure to thrive because he just wasn't gaining weight. And just was a very very poor feeder as a little guy. And mom 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, oh he's just a fussy kid, he's just a dysregulated baby.

It just is what it is. Just go home and keep doing what you're doing. Which is awful. 

Bri: I'm sure it was like, just keep pushing the volume. Not focusing on the quality of, of the feeding experience at all. 

Katherine: Yep. That is absolutely what it was. And I don't think that he even saw a speech pathologist in the hospital.

I think it was just like a medical admit so, very hard for mom and for this little guy as well. So, he was then referred in for speech pathology for being a late talker. 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 some play and I took the phonemic inventory. We did an oral mech exam. We used our picture cues; he was very able to follow instructions. Mom had also very kindly brought him a lollipop to help with some of the tongue movement targets. So that was lovely. And I watched him eat.

In terms of his communication. He didn't have very many words. The words that he did have when I went back and looked at it after, I didn't think this up at the time, but the words that he did have, all of his sounds were bilabials or liquids, there were no lingual sounds at all. When we did the oral mech exam, structurally, everything looks pretty good functioning,

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 go to that particular side. And then when he was eating, he was really functional, actually 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 lateralizing the bolus to both sides. He was constantly moving it to one side and then swallowing. And so, I took all of this data. And then, I was like, I need to think about this. And I went through it all and there was a pattern emerging there.

No lingual sounds no movement of the tongue to one side, either in the task where I was just asking him to do it in a de-contextualized way or during chewing some food that should have required lateralization to both sides. And so, this was one where I was really chasing the why and really interested in figuring out what exactly was happening here.

And I ended up digging into his medical data along with his regular speech pathologist. And he had actually been to a pediatrician for some tests. They hadn't had a meeting with the family yet, but they'd done an MRI and they found that he was missing one of his hypoglossal nerves.

It just wasn't there! 

Bri: Wow. 

Katherine: Yeah, like wow that explains everything. 

Bri: Yup. 

Katherine: So, he just, yeah, he had the innervation on one side of his tongue, but not on the other. And that was just a genetic thing that had just happened. And yeah, everything kind of came together, but it was just a really nice example of how I got data from speech that corroborated the data I got from feeding, that corroborated the data I got from the formal 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 diagnosis so yeah.

Bri: That's a great point as well, because if we are having oral motor difficulties, we should see that across the board with what we're doing.

If we're seeing just issues with one part in one activity that might tell us something else is going on versus the very specific oral motor skill, cause that's what we really should see across the board. 

Katherine: Yeah, absolutely. The second part of my PhD was assessing a whole bunch of three-year-olds and I did the oral motor subtest of the DEAP on these three-year-olds, which has all decontextualized, kiss and then blow, or blow and then smile.

And so many three-year-olds could not follow decontextualized 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 have no known genetic abnormalities. And obviously a percentage of those would have had developmental issues because it was a population sample.

But there were plenty of kids there who scored normal on their speech assessment, normal on their language assessment, but couldn't follow an instruction about oral motor tasks to save their lives. 

Bri: Yup. Yup. That's why I am a huge advocate for doing a functional assessment and taking into account all of that because 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 of 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 a diagnosis of spastic quadriplegic cerebral palsy was born at 33 weeks with a grade four hemorrhage that they had right at birth.

And the therapist that was seeing them just felt it was just out of her wheelhouse. And I honestly respect them for saying, hey, you need to go somewhere else. 

Katherine: I don't feel equipped to assist. 

Bri: Right. So, when the child came to me was being seen by a variety of professionals, ENT, neuro pulmonology, neurosurgery, OT, PT, ophthalmology, we had the wheelhouse covered. But was coming because we are now two years old in one month. 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 him any, because we're just swallowing. There's no chewing happening at all. So, when I 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 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, you know, was pretty receptive to everything.

And I was like, okay, like, it seems like from that cognitive level, we're about a two-year-old which is great. And so, did the oral motor exam really during feeding trials, like, just show me what this looks like and with the bottle cause that's kind of all we were doing for drinks.

We, we were okay. I mean, we latched, we sucked on the bottle, but a lot of spillage 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, I always have to put like a bib underneath to 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 we just tried to immediately swallow. For the oral motor exam, 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.

 We tried with the Veggie Straw at first with lateral placement to see - well what's going to happen if we do. Would bite and then just suck on it. Suck, suck, suck until it was mushy and then would swallow it. SpaghettiOs. - we just swallow those holes. There was no chewing going on.

It was interesting with this child, immediately I'm noticing, okay, we don't have good lateralization and even trying it in a more decontextualized way. Cause you know, nervous about this child swallowing everything whole, I don't really want to test them too much with a solid food, 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 cause like no tongue movement at all. Like, putting some stuff on the spoon and bringing it over, can you come get it over here? I mean, just none at all. Yes. Like child's 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, offering more and more opportunities to lateralize, practicing, biting. Let's do it in tulle first. And then we'll progress to small pieces and work from there because mom's really nervous about that.

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.

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'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? Move 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, poor tongue protrusion. But then I do it again with like, okay, let's take a bite.

 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 was 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.

Katherine: Yeah. 

Bri: So yes, it might give you a little inkling of it, but just like you said, you even, 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. 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 child had come in like that initially we probably would have been like, oh, my gosh, we can't offer any food. There's no way we could do food let's just do purees, but we have to give those opportunities to see what they can do when given the chance, because I think it can shed a lot more light on what they can do from an oral motor perspective. 

Katherine: 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.

That if a child can do something in a functional context but 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? 

Bri: Yep, exactly. 

Katherine: Straight to the functional context. 

Bri: 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 lateralizing a bolus to chew like that skill it's not necessarily going to translate over there.

And so, I think that's important too. This is kind of getting off on a tangent as well. Cause 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 if they're not accepting food that we can try, will they accept it in the tulle? Okay. They won't accept it in the tulle or cheesecloth, will they accept it off of something else maybe then we are introducing something, but still trying to make it as close as possible and then as quickly as possible eliminating those.

For me, I like to think that way backwards because oftentimes a child surprises me on what they can do versus saying they can't chew. I'm going to start at that lower end. With decontextualize active exercise of chewing when maybe we could have already been up a couple steps higher.

Katherine: Yeah, yeah, absolutely. I get asked that question all the time as well. What if they won't accept the food? How can you work on it functionally then? I guess 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.

Bri: Yeah. I absolutely agree maybe your rapport building and their relationship with food and their anxiety around the meal, like that has to come first because if you don't have that trust and relationship.

You could chew on a chewy 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. 

Katherine: Exactly. You have to go more bottom up. Absolutely. As you say about the relationship. And I think there are some kids where, oral motor skills and acceptance just get really enmeshed.

And as you say, for those kids chaining it as quickly and as closely as possible, is a really nice approach. Often when I think about kids where the reason that they couldn't do functional oral motor practices because of acceptance, I'm like, well then acceptance is where we need to start. Not on a decontextualized oral motor task. 

Bri: 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.

Katherine: 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 do in our, you know, in our few sessions or one session a week. I agree. 

Bri: I agree. Well, is there anything else to add? I feel like we covered - 

Katherine: we've covered a lot. 

Bri: A lot.

Katherine: Which is great. No, I think, I think that's everything. I yeah, I just, yeah, I just think. Calibrating your system by looking at as many normal kids feeding as possible and if you have a scoring form or an observational sort of form that you use for scoring, the way that kids eat, use it on typical kids and see how they come out just to figure out where those things sit. I think that can be really powerful. And just thinking, thinking in terms of effectiveness, efficiency, and accessibility, and just keeping on coming back to those things and I think you can't go far wrong when you're keeping those in mind.

Bri: Yep. I agree. Well, thank you so much. I appreciate you coming on here and chatting with me again. It's always such a pleasure to have you. 

Katherine: Thank you, I really enjoyed it. 

Bri: 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.


•Dr. Katherine Sanchez episode from season one on tongue ties



•The Dysphagia Disorder Survey


•CHOMPS with the feeding flock research group





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