Goosebumps in Pediatric Feeding: Overcoming Fear-Based Decisions Through Critical Thinking


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 telepractice.

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 today I am joined by Tovah Feehan, and she is a speech language pathologist and certified lactation counselor who is going to talk with us today about critical thinking skills, what that means, how to build them. Little bit of background and then I'll throw it over to Tovah to give us some background on her, but Tovah and I met on Instagram as I meet many people. That is one of the benefits of Instagram for sure, and we very frequently brought up the topic of being able to think critically as a clinician. How can we like support students with this that are going through SLP programs? And I finally was like, let's do a podcast episode on this.

I think more people need to hear us talking about this, this subject. So I'm really excited to get through and talk about this today. I think it's a really, really important topic and something that ultimately can help you as a clinician and or if you're a student listening for lifelong learning. I think it's really important to support you throughout your career.

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 now 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. Awesome. 

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.

You talking about how like your flow from, you know, like going to early intervention to the hospital to then like teaching made me think about how, you know, like in a lot of med schools they talk about like this application of like see one, do one, teach one.

And it like kinda makes me think about that and like I feel that when I'm teaching students of like I have to know it to a whole other level. Oh my God. Yeah. 

Which is where I'm not saying like, oh, you have to be teaching courses in a university to get to that level. But like I highly encourage people to like supervise and mentor and like provide that.

Because when you do that, you, first of all, you're gonna learn new things, because your student's gonna be like, well, what about this? And like, I hope to learn things from my students, but also like, you have to really know what you're doing to be able to provide that information to somebody else. 

Tovah Feehan: Yeah. 

Brianna Miluk: And I think it's not just like, Hey, do this because this is how I do it, but also being able to provide the rationale behind it, being able to provide the evidence behind it, like- 

Tovah Feehan: Right.

Brianna Miluk: It just forces you to really read into that piece. Huh. So that's just like immediately what came to my head when you were saying that. Cause I was like, that's kind of what you did. You went from like, seeing it with like- 

Tovah Feehan: That's so true. That's so insightful. 

Brianna Miluk: Mentoring to doing it at the hospital and then now you're teaching it.

Tovah Feehan: Yeah. And I think with every new phase, for me, there's been so much discomfort because I wanna be good at stuff. I wanna be the, like, I'm a perfectionist. I'm really hard on myself. And so when it's new, it, it takes time and it takes a lot of effort. And I think that applies to critical thinking too, where like on the front end it can seem really overwhelming, all the pieces of the puzzle with pediatric feeding and swallowing that, that we have to kind of like put together and then figure out what we're gonna do.

And I think in the beginning it's overwhelming and it could be tempting to just do like a cookie cutter kind of program or- 

Brianna Miluk: Regurgitate. Here's the information. 

Tovah Feehan: Everybody else is doing in front of you. Yeah. And so like on the front end that might be super tempting, but just in reflecting, I've been reflecting like leading up to, to talking to you and thinking that yeah, it's more work on the front end. But then now I would love to do some kind of measurement of how many treatment sessions I need with a family because I think it would be a lot less than, first of all, than when I started. But also I'm kind of losing my train of thought, but does that make sense?

Brianna Miluk: No, it does make sense, like almost like a comparison to like when you first started as a clinician, but also thinking like, oh my gosh, my brain's going in like five different directions now.

Tovah Feehan: I know, me too. I'm sorry. 

Brianna Miluk: Between the two of us, it's fine. So what I'm thinking though is like, okay, when I, if I saw the same family. When I first started in my CF versus if I saw the exact same thing right now, how much more efficient would I be? 

Tovah Feehan: That's what I'm trying to say. Thank you. 

Brianna Miluk: Of fine tuning my critical thinking skills. Yes, absolutely. 

Tovah Feehan: Like, okay, so for myself, there's that efficiency where in the beginning I would see a family and I'd be like, are you okay if I record some of this and like share it with my mentor? I'd be open about it and I would have to leave and I would have to take notes and look things up and talk to- 

Brianna Miluk: Yes. 

Tovah Feehan: Yes. So that efficiency for me is there, but also thinking about if I were to use that manual, that like cookie cutter manual on day one, you do this and on day two you do this, blah, blah, blah. That, that might make you feel comfortable in the beginning, but again, so inefficient. And then like you and I talked before about how.

It doesn't matter how many quote unquote years of experience you have. 

Brianna Miluk: Yes. 

Tovah Feehan: What is the quality of that experience? Are you doing the same thing and using your same, you know, workbook for every- 

Brianna Miluk: Yes. 

Tovah Feehan: Or are you like, you know, constantly learning and growing and? 

Brianna Miluk: Mm-hmm. Yeah, that's what the first time I heard that was from Dr. Ianessa Humbert, where she said like, okay, you have 20 years of experience. Do you actually have 20 years of experience or do you have 20 years of the same experience? So you have one year of experience 20 times, or do you have 20 different experiences and like, that's what you're seeking for. Because if you have someone that's just done the same thing over and over and over again for 10 years- 

Tovah Feehan: yeah. 

Brianna Miluk: That's cool but I would rather go for the person who has five years of evolving and changing and, you know, challenging their beliefs and practices than that person who's like, no, this is just how I always do it for 10 years. So. 

Tovah Feehan: And I think to do that it takes to be a good critical thinker, you have to be open, that things are evolving and that you might look back, like I look back on some things I did in therapy and I feel so cringey and I wish I could call families and apologize, but I know that would be inappropriate.

Brianna Miluk: Yes. Oh, I've had that thought too, where I'm like, could I, what if I just like talk to them and they, meanwhile they've not thought about me ever like. 

Tovah Feehan: No. 

Brianna Miluk: But I still think about them all the time. 

Tovah Feehan: Yeah. No, I do feel I do feel bad about those things. And, and it's also like you mentioned Dr. Humbert and her, she has taught me so much about thinking outside the box and like why? Well, why, why are you doing that? Why, what do you matter actually? And does it matter? Yeah. Does it matter really? Yeah. No, I It's her courses are for the adult population. But thinking about how that applies to pediatrics and how we think about it is, oh my gosh. 

Brianna Miluk: Well, her, her podcast, I'm gonna tell you to go leave my podcast. Go her podcast. Her podcast is Down The Hatch. If I didn't say that clear enough. It is also great and I think that, you know, for a pediatric therapist so much is relevant to.

Tovah Feehan: Oh my gosh, it's fire. Even how she talks about, like, I know we were gonna talk about this later so we can talk about it later, but thinking about like what are the things that we're sort of just on autopilot doing and taking her course really helped me with that because I think, you know, when you're in a busy setting, whether it's like hospital or whatever setting you're in, I'm just saying hospital cause that's when I know the best. But. 

Brianna Miluk: Yeah.

Tovah Feehan: You'll have these clickable templates to go through an evaluation. 

Brianna Miluk: Mm-hmm. 

Tovah Feehan: Or to go through a treatment session. And it can become that, it can become, that, it can become autopilot. And it's like, am I actually getting a picture of this child and the nature of how they're functioning and what we need to work on.

And did I actually even see that? Like I, if I'm doing a clinical swallow evaluation for a child there's a clickable box in there. Like, did they have a delayed swallow initiation? And people are clicking that box and I'm not blaming them, but it's like, cuz I did that. But we have to pause. 

Brianna Miluk: It's there, it's there. I feel like I should click it. 

Tovah Feehan: There. It's there, I feel like I should click it. Yeah, don't click it. You didn't see them swallow. You have no idea if their swallow initiation was delayed. You can comment if you notice things like if they were gulpie or if you notice increased work of breathing or nasal flaring or something like that.

But like, yeah, don't, don't comment on things that you can't see. That was a, and I didn't even realize I was doing that. So yeah, being open that things that I'm doing could be better it's definitely helpful with critical thinking. 

Brianna Miluk: Yeah. I think too, like, I mean we can just like go ahead with that, that topic of like critical thinking.

Tovah Feehan: Yeah. 

Brianna Miluk: Versus like going with what the practice is. Like what - well everybody else's click in the box. 

Tovah Feehan: Yes. 

Brianna Miluk: They click that box on every swallow study they do. So I guess we all click the box on that swallow study and it's like, Well, no, and I think so much of critical thinking is just slowing down. Like if you can just slow your thinking by like a 10th of what you're currently thinking at, usually that's like, it's like that's enough for you to be like, wait, why did I click that? Literally just that question. 

Tovah Feehan: Yeah. 

Brianna Miluk: Right? 

Tovah Feehan: Yeah. 

Brianna Miluk: To just tell yourself like, okay, if I can slow down enough to tell myself why or why does it matter? I think that's also one, not just like, why did I put that, but like, does it even matter? So, or does it make a difference for this individual patient? And I think that goes into some research stuff as well, right?

So if we're seeing a study, for example, I find this a lot in tube weaning research. So I'm gonna just like, I'm just like throwing this out there. Okay. I feel like this is not directly related, but kind of related. Okay. 

Tovah Feehan: Yeah, let's go, let's go. 

Brianna Miluk: But they do it a lot with tube weaning, where they talk about doing like very intensive tube wean programs versus more child led tube wean programs.

Okay. And sometimes what they'll find is like, it may take like one day less to get fully off the tube feed. Okay. By doing like a, a more very, very intensive versus like, let's just remove a little bit, let's like decrease at a slower rate. Okay. So let's say there's one day difference. Statistically that is significant, but clinically is that significant?

Tovah Feehan: Yeah. No. 

Brianna Miluk: And that's, yeah, that's the part where I'm like, okay but like. You like took this child's feeds away super, super quick. That was probably really hard on their body and mental load. And so like.

Tovah Feehan: The family too, that's like. 

Brianna Miluk: Yes. And the family being like, oh my gosh, oh my gosh. Oh my gosh. And in a, an intensive program, you're probably following up at that hospital three times a day.

You're going in, you're doing all this stuff versus more it's that child led where like it's a little bit slower and maybe you're checking in once a day, but like a phone call or a video, you know? And like thinking about this now, some child led weans can take a lot longer, but I'm kind of thinking about this like sort of a mix of child led and physician-led where you're like, let's reduce 10% every day.

So a small amount versus like cut 50% day one, cut 75% day two. And so I bring that up though because that's one in the literature that I see a lot where it's like, okay, statistically that's significant, but the critical thinking piece tells you. But is it clinically significant? And so like that's the part that like we have to reflect on, which is where I love like implementation research.

And I think more and more researchers are moving towards saying, Hey, this is what we found and this is how it can apply clinically, which is where having clinicians involved in research is also very important cuz they can provide that reflection. But even for you as the person consuming that information, it's like, cool, that was statistically significant, but how does that matter to me and the caseload that I'm actually seeing?

Tovah Feehan: Right. Yeah. 

Brianna Miluk: So that kind of made me think of it though of like that, like the critical thinking versus like going with the, the like flow kind of thing of like, oh, well, like the research said this. And it's like, I mean, everyone who knows me knows that I'm a proponent for like, what does the research say? But like it only matters to a certain degree. 

Tovah Feehan: Yeah, well, it ma- and context and even you mentioned MBS IMP. So so in my dysphagia course, the students take the MBS IMP course because I think it's really cool. They get so much exposure to so many swallow studies and so many different types of, in like a range of anatomies and, you know, just so much practice with that.

But it is very, it trains you to be very black and white and score and what is it, but it's not gonna give you that critical thinking, that application piece, which is beyond important because okay, you can check those boxes and you can identify them, but now what? You have a person in front of you who wants you to tell them what they should do when they leave. Or like, you know, you have physicians waiting on you to tell you. 

Brianna Miluk: You're like, well, according to this, these things. And they're like, so what does that mean? 

Tovah Feehan: They had a 2 on their tongue base retraction. Yeah. Like, OK. Yeah. So that and that critical thinking piece, that, that is hard. And I think it's hard too, if we're thinking about students where they're coming from an undergrad background where everything is black and white and multiple choice and true and false.

And, and then in, even in graduate school, a lot of it I think it's really hard. When I looked at the definition of critical thinking, it was like, I forget it was the Oxford Dictionary definition, but. 

Brianna Miluk: I'll pull it up. 

Tovah Feehan: Pull it up. Because it said something about it said something about like how prof- professors have a hard time with this.

Brianna Miluk: Yes. So it says critical thinking, noun, the objective analysis and evaluation of an issue in order to form a judgment. And the sentence is, professors often find it difficult to encourage critical thinking amongst their students. The fact that that's their their sentence is so funny. 

Tovah Feehan: I know, I know. 

Brianna Miluk: It is, well- and I think that, so it's funny cuz they say encourage critical thinking cuz I don't know that critical thinking. Here's, okay, here's like a a, I guess, like a, what's, what's the word I'm looking for? Unpopular opinion. I don't know if it's an unpopular opinion, but a hot take. Hot take. I don't think you can directly teach critical thinking. I think you can facilitate and encourage, but I don't think you can directly teach it. 

Tovah Feehan: Yeah. 

Brianna Miluk: I think you model it. Yeah. And you like encourage and facilitate opportunities to learn it. But I truly think it involves like internal reflection and internal learning to where you can't like teach it directly.

Tovah Feehan: Yeah, I know. I think that's a lot of therapy too, right? Like you're not gonna make it eat, you're not gonna make a family follow through on recommendations. You're meeting people where they're at and then. 

Brianna Miluk: Mm-hmm. 

Tovah Feehan: Tapping into that internal motivation. And yeah, I and that's something that is actually really freeing because I would take it so hard if if students weren't you know, picking that up or if I have a family or a child where things are stalling and it's like I have to know where my responsibility ends and I'm not- 

Brianna Miluk: Yeah. 

Tovah Feehan: In charge of like, quote unquote fixing people or making people do anything. I'm gonna offer what I can offer and then, yeah. 

Brianna Miluk: Yeah. We facilitate and encourage.

Tovah Feehan: Yeah. 

Brianna Miluk: That's, that's the role. That's the role. I wanna go back a little bit to the critical thinking versus kind of just like, you know, checkbox thing. And I want you to talk a little bit about, cause I don't do swallow studies, so I want to hear your take on instrumental like rules and how that like doesn't necessarily apply to real life and like how to kind of think through that process. Because I know as like the therapist who gets a child, you know, I get the results from the swallow study, but then I'm like, okay, but like how was it set up? What did you do? How were they feel- like, and so I would love to hear more about, about that part.

Tovah Feehan: Oh my gosh, there's so many things. Okay, so let me talk about, swallow studies are amazing and they give you obviously insight that you would never have if you weren't able to utilize that technology. Amazing. And it can really inform your treatment plan, but there are also other things to consider, like usually in a swallow study a baby or a child is positioned absolutely perfectly.

Oftentimes in seating equipment like that they do not have access to in their home like a Tumble Form. Or the opposite sometimes will have a wheelchair and it doesn't fit in the, in the space to do the study. And so the child is in a chair that's unfamiliar and maybe not in as optimal of a position as they're used to.

And then if we think about if we think about trauma and we think about children who many times have been through many procedures and studies and things that are, that feel invasive or uncomfortable and we're asking them to sort of like perform. And it's. It's a performance. It is, it's not.

Brianna Miluk: Yeah.

Tovah Feehan: You know, we can try to make them as comfortable as possible and play songs that they like, or, you know, show them videos that make them comfortable, have 'em hold a lovey, whatever. But at the end of the day, it's still, it's not, it's not the same as being at home with their family and trying to use. But I'll say like, so when it's like, oh, we do it this way and like you start with this this viscosity and you work your way up and you only use the, the very, the brand and blah blah blah and getting pushback in the beginning for mixing it with a child's actual drink or their actual food because it was like, but I wanna see what they're actually doing.

And also it's way more motivating cuz it's what they're used to. And so that's something where I feel like more and more people are starting to do that, but it takes someone being like, why, why are we doing this? How is this helpful? Yeah. And even I had a message yesterday from a mom who got a repeat swallow study done.

I didn't do this study and she said that this is, this child has been through so many surgeries, so many so many studies, so many FEES, and she had to do one for an upcoming surgery. And she was crying, she was gagging and they had mom syringe boluses into her mouth and she didn't aspirate, which is shocking, but if she did, I'd be like, well, yeah. If someone was like. 

Brianna Miluk: Yeah, it's not applicable to when she's, yeah, calmly sitting at a table. 

Tovah Feehan: Right. And then they actually recommended at the end of the study that they repeat it again after sur- yeah. And this is a child who is doing so well with just like a few visits of therapy. And it's, yeah, it's just. 

Brianna Miluk: Mm-hmm.

Tovah Feehan: *Grunts* Yeah. So there's a lot, there's a lot of different people's normals too, like in different parts of the country or different institutions. 

Brianna Miluk: Well, and even like places where the therapists that are doing the swallow studies are primarily adult based therapists, but they're also just, Hey, even though you don't do pediatric therapy, like be just because of limited numbers in hospitals, it's like you still have to do pediatric swallow studies.

Tovah Feehan: Right. 

Brianna Miluk: So like they do that and it's just not the same when we're looking at like applicability and like tolerance. 

Tovah Feehan: Right. 

Brianna Miluk: Of them. Like it's. 

Tovah Feehan: Yeah. 

Brianna Miluk: Kids don't like them. 

Tovah Feehan: No they really don't. And the other thing is if I, if I call myself out and think about a study that I did when I was first starting to do swallow studies, and it's like you get so conditioned to look for the impairment and to look for what's like not normal. And that was before I understood that there is such a variation in normal. 

Brianna Miluk: Yeah. 

Tovah Feehan: And I think we're still really trying to figure that out with pediatrics and when we think about aspiration and how much is too much 

Brianna Miluk: *Talking over each other* normal. 

Tovah Feehan: Yeah. But I remember one family in particular where, if I think about bias, I, I was seeing what this baby was doing when they were feeding. I had a picture of what it was gonna look like on the study and and so I was looking for any, anything that didn't look typical, anything that was going wrong. And I remember pointing out this like minor delay in swallow initiation, but the airway protection was there, it was functional and I really harped on it and I think. I mean, it's one of those things, right? Where like they're probably not thinking. 

Brianna Miluk: Well that's sort of like an example of confirmation bias. 

Tovah Feehan: Confirmation bias. Yes. 

Brianna Miluk: You had an idea of what you wanted to see and so you were looking for that validation that you were already. 

Tovah Feehan: Yeah. 

Brianna Miluk: Like. 

Tovah Feehan: Yeah. 

Brianna Miluk: Confirming the belief you just already had of like, what's gonna happen on this picture?

Tovah Feehan: Right. And then the other problem with that is that I look back and I feel really bad because I, I perpetuated fear for those parents with their baby and maybe gave them more restriction than, than what was actually needed because of my fear and because of, of me just like not having the knowledge yet of that variation of normal and being able to synthesize all the information, all the pieces of the puzzle, so.

Brianna Miluk: Mm-hmm. Yeah. Well I think, you know, I'm gonna kind of like lead us to this next topic we wanted to talk about, cuz you mentioned fear, which is, fear-based decision making. 

Tovah Feehan: Yes. 

Brianna Miluk: Versus actually-

Tovah Feehan: I like your little segue. I like that. 

Brianna Miluk: I know, it worked out really well. So actually like thinking about like why and how and like examples of like this fear-based decision making, cuz I think this is something that comes up a lot.

And I know like, I used to be the same way of like, can I offer something by mouth if they've aspirated every consistently-cy, you know, if they're found to be a silent aspirator, silent aspirating, every consistency. Like, what do I do? I, I don't think I can give them anything by mouth. So like, should I just give them like a non-nutritive thing to just.

You know, see, see what happens. And so yeah, 

I would love to hear some examples of like how this plays how you've seen this in clinical practice, in your practice. I'll talk about how I've seen it in my own practice, you know, and but also just like across the board how we can fight a little bit of fear-based thinking and make sure we're thinking critically and not being led by fear because that, you know. 

Tovah Feehan: Yeah. 

Brianna Miluk: Sometimes can happen. So yeah, if you could just shed some light on that and, and start talking about some examples there. 

Tovah Feehan: So I was thinking about this a lot since we talked last week, and I was actually thinking about something that you said I can't, I forget, I can't remember how you worded it.

Like you can't teach critical thinking. 

Brianna Miluk: Yes. I feel like you cannot directly teach it, but you can facilitate and encourage. 

Tovah Feehan: Yes. 

Brianna Miluk: Critical thinking. Mm-hmm. 

Tovah Feehan: Yeah. And I just wanted to make sure that it's clear that you can learn to be a critical thinker. 

Brianna Miluk: Yes, yes. It's something you learn. Absolutely. 

Tovah Feehan: Yeah. But it's like nobody can make you learn it.

Brianna Miluk: Yes, exactly. It's not like I can be like, read this thing and now you're a critical thinker, like 

Tovah Feehan: Yeah, yeah, yeah. 

Brianna Miluk: Like its active. Both parties have to be active. In learning it. Yeah. Glad you clarified. But again, I told you like, that was kind of like my hot take. It's not like I'm, that's not like proven, you know what I mean?

Like I don't have, I don't have any science behind that piece. I just feel like through even my own experiences of refining critical thinking is where it's like, whoa, this isn't something I could just read about and be like, oh, okay, cool. I know how to do this. 

Tovah Feehan: Yeah. 

Brianna Miluk: You have to actively engage in it more ongoing. So yeah, continue. 

Tovah Feehan: So I have so many examples of fear-based versus critical thinking, and a lot of times the more I thought about it, I feel like fear-based thinking just comes from not having other ways to think about it, and so when I'm, when I'm feeling afraid about a patient, even now it might be because like I have questions about what I'm doing, and so instead of just acting out of fear. I need to be able to ask someone for help and look for resources and figure out what I'm gonna do so that I'm not operating out of that fear that I have, but I'm operating out of like what's best for the patient. And I think it also comes from when we put too much pressure on ourselves that we're the ones who have to like fix, like we have to fix it, we have to fix our problem and do therapy and that's not helpful to do things to people.

So, so we talked about oral stim a little bit and there's definitely a place for oral motor and figuring out what we do with our mouth when we're eating and progressing functional skills and therapeutic touch. And there's so much there that can be really beneficial. And so I think what we're talking about with fear-based thinking is more like getting stuck somewhere where you're doing the same thing week after week and you're doing these things where you touch their face and you rub different parts of them, or you progressively move and you have them like kissing food but you're kind of like, you're not moving forward.

That's where we can start to feel fear, cuz it's like, really, what are we doing? Like we shouldn't, if we're stuck, it might not be. And I find a lot of times clinicians are quick to say like, well, they're not ready for feeding therapy, or like, they're plateauing instead of looking inside and being like, well where can I find more help for this?

Like, what's something that I'm doing that might be preventing them from moving forward? Is there another aspect to feeding that is tricky for them. Are they stressed out? Because you definitely can't learn when you're stressed out. So just starting to look at the different pieces of the puzzle if you're stuck or if the person that you're working with is stuck.

Brianna Miluk: Yeah, I absolutely agree with that. I feel like that resonates so much with how I think about fear-based thinking as well, is that a lot of times, like I, I use the phrase a lot, like I fight fear with knowledge. 

Tovah Feehan: Yeah. 

Brianna Miluk: And I truly think that like so many times when I'm afraid, and that's like not even just therapy related, anything related.

Tovah Feehan: Yeah. 

Brianna Miluk: Like a family re- member, receives a certain diagnosis and I don't know what that is. I don't know what that means, like. I will fight my fears about it by learning more about it. 

Tovah Feehan: Yeah. 

Brianna Miluk: And so, yeah, it's like, okay, well I could stay and just say, oh, I'm just gonna be scared. I'm not gonna read about it. I'm not gonna learn about it. I'm just gonna stay here. But there's other things we can do- 

Tovah Feehan: Mm-hmm. 

Brianna Miluk: To learn about what's going on so that we don't get stuck. And you know, thinking about that oral motor example, it is, it's like, yes, there's a place for so many different strategies and what works for one patient might not work for another, but we need to make sure that when something's plateauing, we're assessing that internal evidence of. 

Tovah Feehan: Mm-hmm.

Brianna Miluk: Okay. Maybe what do I need to change? Is it, is it the reason I'm not seeing progress or a different response from the child? Not because of them, but because of what I'm providing. The antecedent, you know, the, the intervention being offer. 

Tovah Feehan: Yeah. And it's so true that I think there's also a healthy fear and a fear that drives us to keep learning.

So it's just about getting stuck. So if I think for myself, like when I first took this job to teach dysphagia, I was so scared, I was so overwhelmed. I was doing all the research and the continuing ed and reaching out to people and because I wanted to make sure that I did justice by this topic and I was preparing graduate students.

And so it was like a good kind of fear that drove me to more knowledge, like you're talking about. Or even when you ask me to do this podcast, like I almost know now that if I feel uncomfortable, like if it makes me like clench my whole body and like wanna poop a little bit, then, I probably need to push myself to do it cuz it's gonna be a really good.

Like learning opportunity, growing opportunity. And I even feel like my brain, I'm learning so much just from preparing and from talking to you. So I think those kinds of things can be really healthy. And I also think it would be bad if people had no fear, because it's not about like fear or no fear, it's like acting out of like doing things out of best evidence.

So it's not like I have no fear, I'm just gonna give this child thin liquid and see what hap- like that's not good either. It has to be an informed approach. 

Brianna Miluk: Yeah, I agree. It's almost like you know, thinking like critical thinking versus fear-based thinking, but like fear-based learning. Like, you know, it's okay for like your learning to be driven a little bit by fear and recognize like, I'm just not sure cuz like uncertainty.

Is going to happen. Right? I truly, I feel like the more that I know, the more I realize I don't know anything, like, I'm like constantly like Bri, you don't really know anything about anything. And so, you know, also recognizing like those, those pieces I think like you said is important. We don't wanna have no fear, but we wanna recognize how we respond to that fear and how we move forward with it.

Yeah, for sure. Okay. Do we wanna provide any other specific examples or? Um. 

Tovah Feehan: We talked about oral stim, what were some of the other ones? 

Brianna Miluk: So one thing I'm thinking about is specifically related to like the NPO patient. 

Tovah Feehan: Yes. 

Brianna Miluk: And then what do you do? Like being afraid to try any type of oral trials? Cuz I think there's, you know, I think there's a difference between you know, just chilling and watching the child where they're at, and actually like therapeutic oral trials, you know? And so I would love to hear your take on that too, about like, you know, the child who has been NPO, they haven't had anything by mouth and like, what do you do? How do you approach that when you have this swallow study that says, you know, frank aspiration, all consistencies, where do you go from there?

Tovah Feehan: Yeah, so if I had a referral for a swallow study for a child who's been NPO? Yeah. So I would have a problem with that because it's like taking casts off of your legs and then be like, okay, now run, but you haven't done anything to help. And depending on how long they've been, NPO there might be deconditioning.

They also, like, if they've always been NPO, they've actually never had any experience. So it's just not giving us an accurate picture of what they can do. And depending on why they were NPO we really a lot of times would wanna start with having some oral trials in therapy and building till they're taking enough so that we're actually gonna get good information from a swallow study.

Because if we go into the room and the baby or that child doesn't wanna take anything or they can't take more than a tiny bit, then we've kind of wasted that visit, radiation, money. Because we're not able to really get an accurate assessment of what their swallow looks like. So I think that's another time where, there can be fear like, oh my God, but what if they aspirate?

And, but really knowing the aspiration is also extremely complex. And it doesn't always mean aspiration pneumonia. And knowing the threshold and thinking about for that specific patient and how much can you try in therapy before, so that, yeah, so that it can be useful. 

Brianna Miluk: Yeah, exactly. I think that the, the fear-based thinking of like, I mean, I've had people ask questions about this or talk about this, or I've heard other clinicians, you know, who do the swallow studies say the same thing, where they're like, if this child hasn't taken anything by mouth, like this is not gonna be an accurate picture of what's going on.

You know, you need to be working on something or the opposite. Maybe there's a child who has been taking things by mouth. There's not really anything super overt going on, but because they're medically complex or, you know, have immunocompromised status. The clinician, I mean, I've, I've heard parents say like, the clinician just like, will not start feeding therapy without a swallow study as a baseline.

And it's like, it's not necessarily how we should be approaching things and we need to say like, okay, like what is going on with the child? Or you know, well they haven't had a, they're five years old now and they haven't had a swallow study since they were 10 months old. Like, let's just update it. It's like, but why? 

Tovah Feehan: Yeah, seeing it annually, but like no therapy has changed and nothing has changed with their eating habits. So why are we radiating them and having them go through this uncomfortable test to?

Brianna Miluk: Right. Yeah. 

Tovah Feehan: Yeah. And I've seen other, lots of other examples too where there are referrals made for swallow study based on the diagnosis, like of a certain genetic syndrome where maybe aspiration could be a piece of it or advancing PO not based on the child and what the child looks like, but based on just some like weird prescriptive number.

Like, okay, we're only gonna do this many mls because they have this diagnosis and then we're gonna increase them. I've seen children get G tubes who didn't need them because they just never tried. Like, they just never got to try. So it is like, it is, there's a lot of gravity to what we're talking about.

Like, I'm smiling, but it's actually, it's pretty heavy what we're talking about because people are trusting you with their most prized possessions and like putting their airways in your hands. So it's, yeah, it is. This is really important heavy stuff. 

Brianna Miluk: Mm-hmm. Absolutely. I think it just, you know, kind of goes into the difference of, you know, making sure that we're not just going to somebody's house and recommending strategies that aren't actually therapeutic in nature. And I think recognizing sometimes, like maybe, and sometimes there are moments right where the, in- like the child may need to reach more medical stability. Maybe they do need to have medication management right now, or they need something else to go on and that's okay.

And I think also recognizing those times where like sometimes it's not always appropriate at this moment and that's also okay, but we wanna make sure that we're not assuming a child is un- not capable of something because of our fear. Like just making sure we're not a barrier to them we're facilitators. 

Tovah Feehan: Yeah. You talk about like presuming competence.

Brianna Miluk: Mm-hmm. 

Tovah Feehan: And just giving, giving children a chance. 

Brianna Miluk: Yeah. 

Tovah Feehan: Just what they can do and what they wanna do I think is really important. 

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

Tovah Feehan: So, I think a huge part of critical thinking is having a really solid understanding of normal development. If you have a really solid understanding of normal development, it really helps you see when things are not going, the way that you go. 

Brianna Miluk: The, the like range of normal. 

Tovah Feehan: And the range of normal.

Brianna Miluk: Yeah. 

Tovah Feehan: And also it helps you pick up on when things are getting over pathologized or overdiagnosed. So I have examples of this that I feel very strongly about. 

Brianna Miluk: Yes, share 'em, share 'em. 

Tovah Feehan: So I just, actually, I just made a REEL today that about drooling and normal drooling. Okay. Your face right now. So drooling- 

Brianna Miluk: You know I'm making that face, because I saw a post earlier today, someone sent me about how drool is never normal.

Tovah Feehan: I literally saw the same one and that's what made me wanna make this REEL. Okay. Drooling is normal for babies. 

Brianna Miluk: Yes. 

Tovah Feehan: Oh my God. Normal. Normal when they're learning a new motor skill, normal when they're teething, normal when they're putting literally every single thing they can find in their mouth. Normal, normal, normal.

Is there a time when there's excessive drooling? Do we see children with neuro developmental disabilities who drool excessively, who might need medical intervention or other things or allergies? Yes. Yes, yes. But to say that anything is always, I mean, I can't. The fear, like the fear that that causes in parents when you over pathologize something that is normal for many babies.

Brianna Miluk: Yeah. That's like one of my, that's one of my biggest pet peeves when someone's like, just because it's common doesn't mean it's normal. I'm like, that's literally how we define normal. By it happens most commonly. Like that would be like, it's not normal to have two arms, even though most people do. And that's the most common.

It's like, you're like, if you reverse that logic or use that logic in any other situation, it doesn't make any sense. Like it just doesn't. 

Tovah Feehan: Another one for me is gagging. 

Brianna Miluk: Bahhhh, yep. 

Tovah Feehan: Gagging is a biological reflex that babies are born with to protect their airway. So we should never ever, ever, I will say never, cuz it's a never be trying to remove, desensitize, a gag reflex from a little bitty baby that is something that matures with time and experience and helps them stay safe.

Brianna Miluk: Yes. I, I absolutely agree. The like getting your hands and fingers in an infant's mouth, like from birth to desensitize. Is not what we're supposed to be doing. 

Tovah Feehan: Right. 

Brianna Miluk: Like they need that gag. 

Tovah Feehan: And if, you know, if you have a really firm understanding of normal development, you know, that that gag reflex, is gonna start out really forward in the mouth and it's gonna mature and move back seven to nine months old.

It's gonna be in the back third of the tongue. So these babies, like, they need to grow in time and experience, and sometimes they do need help for sure. Like it's, it's not black and white, but to say like, oh, we have to like de- Oh yeah. 

Brianna Miluk: But understanding that normal piece, right? So like, okay, typically what we would expect is this. Yes, yes. There's exceptions to that. And that's when children need a little bit more support. My big one with this is that reflux is never normal. And- 

Tovah Feehan: I've never heard that one. 

Brianna Miluk: Ohhh. Yeah. Oh yeah. Reflux. That's the big one. That's, reflux is common, but it's never normal. It's like literally anatomically it's normal in an infant and it makes my eye twitch. If you were watching the video right now, you'd see it's twitching. That's the big one. There's so much fear that's like a whole, like there's a lot of fear mongering about reflux and how parents are supposed to respond. I, if you're listening, I wish you could see's face because. 

Tovah Feehan: If you know normal development, you know that gastro esophageal reflux is a part of normal baby life and it's a part of their digestive system maturing and them gaining postural stability and all of these things. And it becomes a disease process when the baby is uncomfortable or disturbed by it. 

Brianna Miluk: Yep. Not gaining weight. 

Tovah Feehan: All of us. And guess what? All of us have reflux. All of us have times that things come back up, but we don't all have gastro esophageal reflux disease. Right. But gastro esophageal reflux is normal for babies. 

Brianna Miluk: Totally normal. Totally normal. Yeah. That's, that's my big one that I get because then there's people over servicing for things that they claim causes reflux, when in reality it's just a normal part of growing and developing as an infant. And the, that's one where I see the placebo effect very heavy because is it the, yeah, placebo effect where they have a certain intervention, let's say they get their tongue tie released because that causes reflux. I'm using cause in quotations because we don't actually have evidence of that. But they claim, oh, they need their tongue tie released because that's why they have reflux.

They have their tongue tie released, they do some oral motor something. The reflux gets better over time, but really the reflux got better over time strictly because of maturation. And so they attribute it to this thing when in reality, normal development tells us it's going to get better over time because that's just how it happens. So, yeah. 

Tovah Feehan: Mm-hmm. 

Brianna Miluk: Ooh. Okay. I'm glad you brought that that up because it's so true. So true. I feel like there's- 

Tovah Feehan: They're gonna come for your firstborn children, Bri, talk about tongue ties. You better watch out. 

Brianna Miluk: I know, right? They're all gonna have it. They're all gonna have one. But, but the thing is like, and that's how. 

Tovah Feehan: No, I mean like, people are gonna come for you. Actually my daughter did. My daughter did have a a tongue tie that was like a classic heart shaped tongue tie that she did have released. 

Brianna Miluk: Mm-hmm. 

Tovah Feehan: And there are definitely times where. 

Brianna Miluk: Yes. 

Tovah Feehan: It's impacting function and it does need to be released for sure. 

Brianna Miluk: Mm-hmm. 

Tovah Feehan: But I think it's about coming at it with an understanding that it is definitely one piece to a very large and complex feeding puzzle and I think in general for me thinking about this with like critical thinking red flags, like if there's like. Like a pill. If it's like, this is your solution, this is your thing that's gonna fix all your problems. And it could be anything. I heard, who did I hear talk about this? It was I think it was the women from Unbiased Science Pod.

They did a podcast with Dr. Mike. And they were talking about how if there was a pill for baldness and being fat and being ugly, like we would all be like skinny and beautiful and have really thick lustrous hair. And so when there are these claims like this solutionism that happens that like, yes, we'll fix this with blah, blah, blah, my- immediately my like, red flags go off.

Like yeah, that's a, that's a.

Brianna Miluk: For sure and, and I agree like it is, it is a real diagnosis that can impact function. The biggest thing is when there's like the quick fix claims or claims that it impacts certain things that we just don't show it as being related to. Right. And I think the other thing is like the for tongue tie, for me it's like the percentage of infants that we see in literature that have a tongue tie compared to the excessive amount being diagnosed with it is where there's just like a mismatch of that.

It's like, you know, there, there may be other things that are going on or other interventions that are more appropriate to start out than going to a more invasive type of intervention. That's kind of my spiel with it. Like I've, I've made referrals for tongue tie releases, but not after trying something less invasive first.

Tovah Feehan: Yes. Fear-based thinking. And this is coming from somebody who takes medication for anxiety.

Brianna Miluk: Yeah, same, same, same. 

Tovah Feehan: I'm gonna have like a low level of fear no matter what, but. 

Brianna Miluk: Yeah. My baseline is.

Tovah Feehan: The baseline is like a little bit scared. Yeah. But in some ways I think that's good because it keeps me it keeps me honest and it keeps me like thinking critically. Cause I'm like, wait, is this the right thing?

Brianna Miluk: It makes me ask why. 

Tovah Feehan: Yes.

Brianna Miluk: Because if I can't justify the why, then I'm gonna stay in fear and. 

Tovah Feehan: Yeah. 

Brianna Miluk: Being able to justify the why I think helps alleviate that for sure. 

Tovah Feehan: For sure. I think, okay, so wait, I just wanna say one thing and then go back to what we were just saying. Cause I don't wanna forget it.

So you talked before we started recording about taking a course or take doing something, reading something you don't, where you come at it with maybe a bias of like, Ugh, I don't know about this. And I think that that is an important part of critical thinking and that fear-based thinking is like, if I'm afraid of something or I'm judging something I have to like make sure I'm understanding it first.

Brianna Miluk: Yeah. 

Tovah Feehan: Because I might not understand why somebody's doing something or recommending something, or I might just not be familiar with that approach. So I, my guards go up, but I have to be like, okay, let me just really see what this is about. And there might be positives in it. Or maybe like you said, if I'm asking why, why, why, why, why?

At least I can feel confident that it's not, it's not my value or it's not an approach that I wanna use. So I wanted to say that while I was thinking of it, cuz it is important to me. And I think it's an important part of critical thinking cuz we can get in our like camps and it can be very polarizing.

And people get closed off to anything that's different or that challenges that bias. And I even, oh my gosh, I should grab it. I have this *clears throat* book that I found at a yard sale from the 1950s about it was what they would give to parents when they would go home from the hospital. It was an infant care book.

It's so freaking cool and it talks in there about how you should lay your newborn out in the sun for 15 minutes a day and you should give them, you're like shaking your head like, oh God, give them. 

Brianna Miluk: *talking over each other* it's just so funny. 

Tovah Feehan: Orange juice every day. And and that's what science and medicine told us then, that that was the best thing for them to get Vitamin D and the best thing for digestion and then you learn better and you do better, but you have to be open to. 

Brianna Miluk: Yes. 

Tovah Feehan: How science evolves and how we apply it. 

Brianna Miluk: Well, and I think too, because I, again, I wanna say this before I forget, is. 

Tovah Feehan: Yeah. 

Brianna Miluk: Something I hear a lot from people is that, you know, rely more heavily on their clinical experience or anecdotes and testimonials than they do the literature is like, well, science hasn't caught up yet. And in fact what we see is that clinic hasn't caught up to science. Now, science takes a while, don't get us wrong, right? Like there's years that go into a study and all of that. But what we see consistently is it takes on average 17 years for research to reach clinical practice as a whole.

So like it's slowly reaching people and going down from there. And so I get like, that's like a pet peeve of mine where people are like, well, science hasn't caught up yet. I'm like, we haven't even caught up to science yet. So like, you can't even say science hasn't caught up yet because. We haven't even caught up to what the science has been saying.

And so I think that's like another, but that's kind of a, a logical fallacy, right? Of like, it's not a rational argument for why you're doing something if we have science that says otherwise. Because a lot of times there is science to help guide it. It's just a matter of like becoming aware of it too.

Tovah Feehan: Yeah, there's there's an OT, I think she might have retired this year, but she's so amazing and she mentored me a lot. And she's just, yeah, she's accomplished so much. She's incredible. And I would ask her, you know, so what courses do you recommend? And she would say, you know what, Tovah, I set aside two hours a week and I see what research is coming out and I look at all different disciplines of research.

And she said, if I'm gonna take a course, I wanna see the references. Before I sign up, I wanna see, you know, what I'm gonna be learning and where it's coming from. And I thought that was such valuable advice. And it is easy to want, like a quick fix or. 

Brianna Miluk: Yeah. 

Tovah Feehan: Hot new. 

Brianna Miluk: I love that though because I fe- I get that question all the time. Like, what CEU should I take? And you know, I have a couple that I was like, this was a good course, I liked this. And so if you like have a specific, oh, I wanna learn about this, I might have an idea of one I would recommend, but routinely I tell people, like, I think you can learn a lot of it by just reading the research.

Like if you just spend the time accessing that. Now that's harder because you have to take that the step further, right? You have to understand, okay, it's statistically significant, but is it clinically significant? How can I modify this to apply it to my patient? 

Tovah Feehan: Yeah. 

Brianna Miluk: It's hard work. But yeah, I.

Tovah Feehan: It kind of reminds me though of like I don't know if this is gonna make sense and I haven't seen this show in forever. I don't even know if it's still on, but you know, like, Who Wants to be a Millionaire? 

Brianna Miluk: Yeah. I think it is still on. 

Tovah Feehan: Oh, okay. 

Brianna Miluk: I don't know who like posts it or anything now, but I think that it's still on. 

Tovah Feehan: Okay. Because you know how there's like three, I don't even know what the three options are. I just know one of them is like, phone a friend or you can get a fax or, you know, there's three whatever.

Brianna Miluk: Yeah. Yeah. 

Tovah Feehan: So even when you're talking about that, like if you're somebody who has a hard time understanding the research or knowing how to apply it, if you have that phone a friend, like if you have a 

Brianna Miluk: Yeah. 

Tovah Feehan: Piece where I know for me, if I have a question about a cardiac baby, like I have my person that I'm gonna call.

Brianna Miluk: Yes. 

Tovah Feehan: You know, and you start to. If you're, if you're having a hard time, you have that in place. 

Brianna Miluk: Yeah, that is true. And I think that's where like having like journal clubs 

Tovah Feehan: Yeah. 

Brianna Miluk: At the place of employment can make such a difference. Even if you just start out with like one article a month. Like even if you start with something small.

So the, when I used to work for an outpatient clinic, we had weekly, so like one time a week over lunch, we would go through and we each took turns like picking the article that we wanted to review so that everyone could pick something like a little more relevant to them and then we would all come together and be like, how did you interpret this?

How did I interpret this? What patient would you maybe use this with? And like, getting some of that critical thinking 

Tovah Feehan: Yeah. 

Brianna Miluk: With it makes such a difference for sure. Mm-hmm. 

Tovah Feehan: Yes, for sure. Because it's, it is a muscle that you, that you strengthen I think over time. 

Brianna Miluk: I do too. I do too. Because I think just as we like learn those things like in clinic, the more articles you read, the easier it gets. 

Tovah Feehan: Yeah. 

Brianna Miluk: To appraise it and understand it and. Yeah. Make it applicable. 

Tovah Feehan: Yeah. Which is what was frustrating for me in the beginning because I was comparing myself to my mentors who had been speech pathologists for, you know, 15 years, 20 years.

Like so amazing and so knowledgeable and just so much experience and and I wanted to be there. Like, I wanna be there now. I wanna.

Brianna Miluk: I just wanna be there right now. I wanna be all of that. Yeah. Yeah. It takes, it takes a lot of practice. 

Tovah Feehan: Yeah. But like, that's not hot, right? Like people want like solutions. We wanna know what pill I have to take. Yeah. 

Brianna Miluk: I don't wanna have to work now. I just wanna like know the research and know the. Yeah, for sure. For sure. Okay, let's go back to fear-based thinking. Let's talk about some examples. No, we're good. We're good. Let's go back to some examples of this and like kind of what, what we're talking about when we say critical thinking versus fear-based thinking. 

Tovah Feehan: Yeah. So, okay. Fear-based thinking could look like a patient that comes in for their evaluation with me, or maybe I'm covering a patient and find out that they've been doing oral stimulation for three months and weekly in therapy. And just.

Brianna Miluk: I wanna clarify to people that are listening, especially if like someone's a newer clinician, like when we're talking about oral stimulation, we're talking about things like NSOMEs or, or like passive. 

Tovah Feehan: Touching their cheeks. 

Brianna Miluk: Massage. Yes. Like touch cheek, stroke cheek. No food involved. No, li- like, it is just like kind of a massage? 

Tovah Feehan: Touching your lips. Yeah. 

Brianna Miluk: Yeah. And sometimes it's not even like, rotation. Like sometimes it's like touch and hold, touch and hold. I'm literally like, for those of you listening, not looking, I'm just touching on my face. Like that's kind of what I'm just doing. 

Tovah Feehan: Yeah. Yeah. And I, and I will add that I'm certified in infant massage and I only say that because I wanna make it clear that there are many benefits to appropriate massage and tactile cues and things like that, 1000000%.

But if we're thinking about therapy and we're thinking about a family's time weekly, and we're thinking about charging insurance, if you're doing that for three months, I would just wonder is that something that the family could just do at home and look for signs if they're ready for more? Or also like, why aren't we trying anything at all? by mouth? Is there a reason? Did they have a study that went wrong? Were they showing signs and symptoms of aspiration? And that's often what I ask. I'll ask families, well, why do you know why you're doing this? And I think that's huge too, is like, we should be empowering these families for their why.

We should be helping them critically think because they know their kid the best. So if we teach them why we're doing things and, and we're the experts in feeding and swallowing and we can empower them, then they're coming at me with like, well, I noticed this this week and he's really motivated by this. And then fire happens. Like. 

Brianna Miluk: Yeah. 

Tovah Feehan: It just takes off because they're the expert on their child. So we're putting together our expertise and just works much better that way. 

Brianna Miluk: Yeah, for sure. Okay, continue. I just wanted to make sure like we understood what we were talking about with oral stim, so. 

Tovah Feehan: Yeah, no, I'm glad you did that. So that that would be one example. And I think in general, like I mentioned, three months as like an arbitrary number, but I think in general, we should see forward momentum. 

Brianna Miluk: Yes. Yeah. 

Tovah Feehan: And if things are plateauing, I think it's easy for therapists to maybe blame the family or. 

Brianna Miluk: Not doing it enough or not doing it right.

Tovah Feehan: Or they're not ready. And I think we have to make sure we're looking inside like, maybe I'm not the right fit for this family. Or maybe they need a different approach or maybe I need to learn to try something different. Cause if we're doing the same exact thing every week, I mean, that's the definition of insanity. We're gonna get thesame *talking over each other unintelligibly* and I'll ask like how- 

Brianna Miluk: The same thing even though it's not working.

Tovah Feehan: How working for you? It's not, ok, so let's try something different. And it's scary. And I think if we- if we're talking about confirmation bias too, with this fear-based thinking, there's fear for these families too. Like, this is the narrative I've been fed for this long and you're telling me something different. Like that's scary. That we're, that we're pivoting here. Like that's hard. And so. 

Brianna Miluk: Yeah. For sure. And I think like going into, this is like a side note, but thinking about approaches like like the oral stimulation or infant massage, right? It's like we also have to remember that many of these are complimentary to the other therapeutic things we're doing. So that kind of goes into that asking why.

So I get questions all the time like, do you use oral motor tools or what about like vibration or what about this? Ask yourself why you're using it. If you are using that because the child's orally seeking and it is supporting their regulation, or it's helping to regulate their body so that they are ready to learn a new skill.

They in that-, then yes. But if you're saying, oh, I'm using this because I'm going to build their oral motor strength, and you have a child who doesn't accept anything by mouth, they could be the strongest kid in the world, they're, they're still not gonna be able to chew the food. And I think that's where like the why question helps you so much of like, why am I doing this?

And if I'm doing this because I wanna build strengths so that they can choose certain foods. Okay, sure, I'll give that to you. But if you're doing that for weeks on end and they're not starting to chew food, you need to pivot. It's not, it's not because they don't have the strength for it, it's something else.

And that's when we also have to recognize like, or I'm using it for regulation. If they're still not regulated, what else do I need to do then? Because obviously that's not working. 

Tovah Feehan: Right. Yeah. I think that's the key too. If you feel stuck or if things are stuck, then yeah. Like we can't get stuck there.

Brianna Miluk: Yeah. 

Tovah Feehan: There were some other ones with fear. 

Brianna Miluk: I love the, like over servicing, over-diagnosing kind of examples.

Tovah Feehan: So I think when it comes to confirmation bias too, and the over-diagnosing, I think it's when it, that fear, you can look at a chart and see a bunch of diagnoses and you can have a picture in your head of what that child can do and what it's gonna look like. And I've actually seen, I've had babies or children get referred for a swallow study or for something like that because of a diagnosis.

And I understand, I understand. But also, like clinically, what are you seeing? What, what are you seeing functionally? What are you looking for? What are you trying to figure out? And are you limiting somebody because of their diagnosis? Because I could rattle off a list of diagnoses of one child, one child who has made significant gains in two, three visits cuz they got the chance.

Brianna Miluk: Yep. Yep. Mm-hmm. 

Tovah Feehan: The opportunity in a supported, loving environment. 

Brianna Miluk: Yeah. 

Tovah Feehan: You know. 

Brianna Miluk: Kind of goes into what we, I feel like this phrase is talked a lot about with AAC, but I find it very relevant to feeding is presuming competence. I think there's, so, there's so many like rules around feeding that people look to because of, again, fear of well, they have to be sitting up totally independently, or they have to be able to be in a 90, 90, 90 position, or they ha, you know, XYZ fill in the blank. Right? And a lot of times it's like, well, I, I don't, like, I've worked with many children who have spastic quadriplegic, CP. They're not gonna sit in a 90, 90, 90 position.

They, they can't. But that doesn't mean that they're not capable of eating food. Or, you know, a child who needs modified positioning, so they can't independently sit up on their own, but their head and neck is supported if you can support their trunk. So if you can support their trunk, they can, they can participate in a mealtime.

But if we presume they are not going to be able to eat, we presume that they're incompetent, then we're, they're never giving that opportunity. And that's where like it goes to like what they look like on paper. Versus what are they actually presenting like clinically? And I think those are also examples are like you get a child who maybe had a swallow study done when they were six weeks old and now you're seeing this child at four years old.

They haven't had a swallow study since. They haven't really eaten by mouth cuz they've gone through therapists that have fear-based 

Tovah Feehan: Yeah. 

Brianna Miluk: Practice. And you go, I guess I need a swallow study to start. And it's like. 

Tovah Feehan: Yeah. 

Brianna Miluk: Are you seeing something that tells you that? I mean, if they're not taking anything by mouth right now, what is the swallow study gonna tell you?

Tovah Feehan: And when we think about both questions, the fear-based thinking and the, you know, just kind of being on autopilot, we would get referrals all the time where it's like, oh, they need their annual swallow study for school. Why? Did anything change? Why? Yeah. Yeah. 

Brianna Miluk: That doesn't make any, any sense? Yeah. And I think too sometimes, like I've also seen that with schools where they're like, well, we won't feed unless we know the diet they can be on.

Like we need the documentation of it. And some of that falls on to us also to support that education piece. Whether you are, you know, the providing therapist or the therapist at the school to say, Hey, school, why are we requiring this for all of these children? 

Tovah Feehan: Yeah.

Brianna Miluk: Why do they need the swallow study?

Because, no, it's not changing what we're actually doing. You know, schools want to cover themselves and that's a lot of times where that stems from. But yeah, if nothing's changed, why are we doing it? Or thinking about too, like children, maybe you've like systematically weaned them off thickener. And I'll always get the question like, oh, well do we need to repeat swallow study if they get down to thin to like make sure they're good.

With thin, it's like, well, are you seeing anything clinically that tells you they're not? 

Tovah Feehan: Yeah. 

Brianna Miluk: And if you're not, you don't need a swallow study like, we don't need a swallow study to confirm they're doing well if they're doing well. 

Tovah Feehan: Right, if you look at the the research that came out of Boston on the, on thickener weaning? 

Brianna Miluk: Yes. 

Tovah Feehan: What was it? In like 2020? 

Brianna Miluk: 2018. 

Tovah Feehan: 2018. Okay. Yeah. You're so good. You know, the year. So yeah. 

Brianna Miluk: I love that article. Yeah, it was Wolter and colleagues in 2018. 

Tovah Feehan: Ok. If you had glasses on, you would push them up. 

Brianna Miluk: Yeah. 

Tovah Feehan: My glasses on, i'll push them up for you. Solidarity. So, so they do talk in that article about how most of the children in that study, and I think there was, I don't know, close to 80 that, that on average they needed one to two studies to in, in the course of their treatment.

And yeah, I think we're really quick to be like, oh, I gotta, I gotta do it. I gotta check this box. And that Y comes in. 

Brianna Miluk: Yeah. Yeah. 

Tovah Feehan: And, and also thinking about. The whole picture and, and what that does to families. I've had parents where a swallow study goes well, and parents, the mom is still hysterically crying after because it brings up so much past trauma and they're so, it's so, it's so heavy.

And so really thinking about the implications of doing those studies and the radiation, all of that. 

Brianna Miluk: Mm-hmm. Yeah. There's so many other pieces to it, and the fear that goes into the caregiver going into it of like. 

Tovah Feehan: Yeah. 

Brianna Miluk: They've been doing kind of well, and if we go to this, are they gonna have to go back to some modified diet that they're, you know, also scared of?

So yeah, it goes into like that, looking at that, that whole picture. I think the other thing I was gonna say from fear-based thinking, is sort of that overdiagnosis or over servicing as well in terms of like someone comes to you and says, Hey, I think like this is going on. And recognizing like a range of normal versus just assuming like, oh yes, it does look like they have oral motor weakness.

Or it does look like they, it's like do they really, like, do they actually have that? And like if you are saying they have oral motor weakness or whatever it is, why, like how, how are you justifying that and actually looking at like the child as a whole? Because I think there's also a piece of like just parents being concerned about X, Y, Z and not like parents don't receive training or like education on like here's a range of normal.

And so they're going to constantly compare and constantly look at those things. And so also being able to provide some of like that guidance and also, recognizing like when our role as a feeding therapist is done. 

Tovah Feehan: Yes. 

Brianna Miluk: Versus like a child who maybe just still needs medical management of what's going on.

Tovah Feehan: Yeah.

Brianna Miluk: But if you've gotten to them, them to that point of like they can safely and effectively eat and enjoy it when they feel, well that's your role. Like that, that is it. And like feeding therapy is not like, it should not be this lifelong or like years on end experience. 

Tovah Feehan: And I think. I think we have to be, think critically about the words that we use with families as well because words carry a lot of weight and I see way too many babies where parents miss out on attachment.

They miss out on those times and being present because they've been from provider to provider that is pathologizing everything and focusing on and calling everything an impairment. Even when we think about that range of normal. And so parents get tunnel vision and they're so stressed and oh, just thinking about all those pieces to the puzzle.

And like for me, a red flag with any provider is like, cuz we know with pediatric feeding disorder there are these different pillars and they intersect. And so if there's somebody who's only focused on one pillar, like only focused on oral motor only focused on behavior, only focused on me medical or nutrition, whatever it is.

To me that's a red flag because yeah, like do they not understand the other pillars or do they not, you know, it, it just.

Brianna Miluk: Yeah, it's very rare you're gonna be Yeah, in isolation. But then also recognize, like that just goes back to that whole picture of the child and trying to understand like what else is going on and what's influencing this.

But also I love how you mentioned like the attachment piece and the connection piece. Cuz like many children we work with are seeing PT, OT, speech. They also have to follow up with the GI and the cardiologist and the pulmonologist and all of these appointments and it's like they lose like being able to just be a kid.

Tovah Feehan: Yeah. 

Brianna Miluk: And just play because when other kids are playing after school, they're going to therapy when other, and so recognizing like some of those pieces as well where like sometimes when we say, Hey, like, you know what? We've gotten to the point where they're doing really well, they're thriving. Like we, they can safely and effectively eat given like what, you know, the strategies we've provided and like, go be a kid.

Like go. It's okay for like, a lot of those other things matter just as much. 

Tovah Feehan: More. Yeah. 

Brianna Miluk: I was gonna say if not more. 

Tovah Feehan: Yeah. And same with thinking about I think this is something when it comes to critical thinking that is so important that has developed over time like I wanted in the beginning of my career to give all the things and know all the things and tell the parents all the things.

And thinking critically about what can that person handle, what can that child handle? What is the priority here? Not giving these long- and even again, thinking about the words we use, like even calling things like exercises or wor- like just making things normal and like making it like when you're eating a meal, just do this.

Like when you're, you know, having it, not everything be so pathologized and so like therapized, it just, yeah. I think that's super important for families. I've had families like one recently where the mom was like, I'm afraid to look at him if he's eating because I'm afraid like, he'll stop. So I usually like turn away and I put the like this green on, you know?

And like from the first visit to the next visit, they were like eating to, I wish I could have filmed it, but they were eating together. 

Brianna Miluk: Yeah. 

Tovah Feehan: And like enjoying the soup together and it was so cool. It was.

Brianna Miluk: Mm-hmm. 

Tovah Feehan: It was so sweet. 

Brianna Miluk: Yeah. I think that really just goes back to how important it is to focus on, like, connection over anything else.

Like that is most important. Everything else can follow if it will, right? Like a child will will follow with all of those other things if, if they can. But if we focus on connection, like we won't go wrong that is like, ugh. Gosh, it's, I could, yeah, I could go on a tangent on that part and how important that is to 

Tovah Feehan: Yeah.

Brianna Miluk: Mealtimes. Cuz mealtimes are about more than just the nutrition that you're taking in. There's, so.

Tovah Feehan: Hey, and it's more about, it's, it's more than what your mouth is doing too. 

Brianna Miluk: Yes. 

Tovah Feehan: Infancy. From infancy. Like, I always, when I, when I meet parents of like newborns or infants, and we'll talk about, you know, I'm a speech therapist, so I think about communication and isn't this beautiful?

That even if your baby's crying, they're communicating something to you and you're able to, to try to interpret it and respond, and you're teaching them as little itty bitty babies already, that they can trust you and that you're gonna res, you're gonna try to understand them and respond and conversate with them as opposed to like doing things to babies.

Brianna Miluk: To them. Yes. 

Tovah Feehan: Yes. It just.

Brianna Miluk: I know I like, this is, this is a total side note, but like it makes me cringe sometimes when, not sometimes all the time when I see this, but they'll be someone like posting a video on social media or whatever and they're doing like some oral motor thing and they're like, watch the baby, like calm down after me doing it for a minute.

And I'm like, they're dissociating. 

Tovah Feehan: Yes. 

Brianna Miluk: You can see the child like retract in. Their eyes, like look somewhere else. And I'm like, that child is not calming down because if they were calming down, enjoying it, they're gonna engage and they're gonna like hold your hand while you're doing it. Like, oh yes, that does feel good. Like, they are dissociating. 

Tovah Feehan: Yeah. I always think about that when I see if I see a family where they're like, in the beginning, like they hate, they come for their evaluation, they hate it, da, da da. And now they, they seem fine with it, and I same. I'm looking and I'm like, Ooh. 

Brianna Miluk: They're tolerating. Like, because they're just like, well, it's gonna happen whether I'm mad or not, so I guess I'll just comply.

And it's like, that's a perfect example of compliance, like based therapy over like connection based, right? So like, do they actually enjoy it? Because I feel the same way about, you know, oral stim and, and things like that. Do I like if someone rubs my temples? And like I'm laying down and they're rubbing my temples and like, oh, this feels so good.

Like, do I love a head massage? Yes. But it's only supporting like a short term change. Like I'm calm for a minute, you know, like during that period of time. And so also recognizing things as like complimentary versus not, and only doing them if you actually have consent from the child that they want that.

Like if the child is upset while you're doing it and they're pulling away and pulling, don't do it. Like especially like that goes into critical thinking as wells. Like that risk to benefit analysis. 

Tovah Feehan: Yeah. 

Brianna Miluk: Of the choices we're making. And you know, if the risk is that like this child is begun, gonna become more orally aversive and the only thing they're accepting is like your fingers in their mouth.

Like what was the benefit you were trying to achieve with that? But if the benefit is that like they actually are calmer and more regula- you know, and, and being supported, then like, okay, it might be worth what we're doing. 

Tovah Feehan: Yeah. I think about it even when I think about babies who are a little older or toddlers and and I always think about it like dating and like you would hold hands right before you, like kiss or like get, and then give tongue. 

Brianna Miluk: Yeah. 

Tovah Feehan: And like have- so it's like, you know, but a lot of times we're like jumping to the se-, like penetration we're getting in the mouth, and it's like you could warm me up a little bit.

And so it's probably inappropriate that I sometimes use that analogy with families, but I do because it's like if that baby or that child is not even comfortable on their hands touching a food and we're trying to shovel it in their face.

Brianna Miluk: Shove It. 

Tovah Feehan: Shove it. Yeah. It's just like, that is so much more vulnerable and invasive.

Brianna Miluk: Yeah. That's why a lot of people don't enjoy the dentist. It's like, even though, you know, okay, they're just gonna touch my teeth, you know, it's gonna be fine. Like, it's invasive. Like 

Tovah Feehan: Yeah.

Brianna Miluk: It's, it is. But like, I don't know, people are just so quick to be like, it's fine. No. Like, put your fingers in their mouth.

It's super great. It's, it's what they need and it's like, no, they don't. 

Tovah Feehan: Yeah. Well, they're gonna tell us what they need. 

Brianna Miluk: Yep. Yeah. Now, if they're mouthing their fingers a lot, oh. Looks like they want oral input. 

Tovah Feehan: Right. 

Brianna Miluk: Have the child who like never touches their mouth. You're like, so we need to desensitize the mouth. It's like, Ugh. 

Tovah Feehan: Yeah, I get itchy. I get itchy. Yeah. It's even like the gag reflex. 

Brianna Miluk: Gosh. 

Tovah Feehan: You know, that's a good thing and it protects your airway and we're born with it and it matures naturally with input and experience. And we do not need to be desensitizing newborn gag reflexes. We need to be. 

Brianna Miluk: To fingers. 

Tovah Feehan: To support. Yeah. 

Brianna Miluk: It's gonna naturally evolve to the things it's supposed to. 

Tovah Feehan: Yeah. And, and we need to support, you know, there are babies that need support that truly have a hypersensitive gag reflex for whatever reason. But again, we're figuring out why. And then matching, you know, whatever supports they need. But I think. 

Brianna Miluk: Yeah, and matching it to like a functional outcome, right? So like.

Tovah Feehan: Yeah.

Brianna Miluk: Okay, we need them to be desensitized or like, not even desensitized, but we need to give them exposures and opportunities to use this, a bottle nipple, right? So that they can be well fed. So that they can be like, we don't need them to. 

Tovah Feehan: And I think even the word desensitized, like 

Brianna Miluk: I know, that's why I stopped cuz I was like, it's not even-

Tovah Feehan: We want them to have their senses. We don't wanna desen- yeah, 

Brianna Miluk: yeah, yeah. No, and that's why I like hesitated cuz I was like, it's not even the word I wanna use. It's just offering opportunity again facilitating, yeah. Providing opportunities. But not like, I'm not gonna sit there and like stroke their tongue to like get rid of this gag reflex.

Tovah Feehan: Right. And I think too, it's, it's hard in, especially in the beginning and depending on the family, it can be really hard to, to coach and to collaborate care with families. But if we again, think about efficiency and like, How many visits, like I just see so many times it's like, oh, we're gonna see them once a week for 12 weeks or we're gonna do, you know, this intensive or whatever it is.

But you know, there, there are opportunities for the right family where you can meet once every two or three weeks. 

Brianna Miluk: Yeah. 

Tovah Feehan: And if you're giving them what they really, the tools that they really need, that child's gonna make just as much, if not more progress. It reminds me of what you talked about in the beginning with like the intensive 

Brianna Miluk: Yeah.

Tovah Feehan: Versus.

Brianna Miluk: Tube weaning. 

Tovah Feehan: Yeah. Where you might get to the same result, but for one, you know, how much better and how much more confident did that family feel in their ability to parent? And how much more time did they have to just be a family or work or yeah. 

Brianna Miluk: Yeah, yeah. Exactly. There's like so many other clinical significance pieces we have to look at with that. Mm-hmm. No, I absolutely agree. Okay. So. We're gonna stop for this episode today. So what I think is, so for anyone who's listening, we are gonna have a part two coming up that we're gonna talk about then how to like, build some of these critical thinking skills.

So again, we kind of talked about my hot take of like, I don't think we can teach you how to critically think, but we can facilitate and encourage and provide some resources that can help you in building critical thinking skills. And then we'll talk about like incorporating critical thinking into a case.

So check out part two to kind of go into like, okay, so like now how can I apply this and what does it look like in, in some cases? And so Tovah and I will go through some cases like based on, you know, real life examples of times that we've had to critically think through, but also like comparing some of the differences of like, okay, how would you look at this case?

Like, I'll present a case, Tovah will blind react, Tovah is gonna present a case. I'll blind react and we'll just like see how we think through it. So. 

Tovah Feehan: I love it because it's gonna be like choose your own adventure. 

Brianna Miluk: Yes. Yeah. Makes me think of those old goosebump books if you do this turn to page, you know?

Yes. Like you get to pick 'em on. So, no, I'm, I'm really excited though because I think it will hopefully be a good example of like, it's not cookbook. There's so many other pieces that come into it, and it's not necessarily that one singular approach is right or wrong. 

Tovah Feehan: Yeah. 

Brianna Miluk: There's a variation that we have to consider.

So I'm excited about it. But thank you Tovah for our chat today, and I'm already so excited for part two. 

Tovah Feehan: Yay. Me too. Thank you. 

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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