The Maiden Voyage

Join Kelly, Lezli, and Dr. Alisha Delgado as she discusses feeding cues in Infants.

Episode Transcript

(00:00):
Hey everybody, this is Kelly Mason and Leslie Carson and you're listening to Episode 1,

(00:19):
The Maiden Voyage of our Early Intervention podcast.
Our goal of this podcast is to provide information to early intervention providers and families
across the state of Kansas and the whole world.
Why are we limiting ourselves?
As early interventionists and parents, we spend a lot of time driving and we want to make
information easily accessible to all.

(00:40):
We hope to bring you a variety of different topics relating to early intervention.
So let's get to it.
Yes, Kelly.
We have a fantastic guest joining us to share information on feeding cues in infants.
Dr. Alicia Delgado from Infant Toddler Services provided by TARC, which is the Early Intervention

(01:00):
Program in Shawnee County.
Kelly, as you know, feeding is something we as providers are supporting families with
often, so who better than to have Dr. Delgado to share information on this topic?
But, before we bring on Dr. Delgado, Kelly, tell me something good.
Tell me something good.

(01:22):
Okay, here is a feel-good story to start your day.
This story goes all the way back to 2017 when Paul and his family were moving from the East
Coast to Arizona.
They stopped at a rest stop and their little dog named Damien got spooked, jumped off his

(01:43):
leash and disappeared.
They spent almost a week there looking for little Damien, but no luck.
Paul and his family had to make the difficult choice to give up and move on to their new
home.
Months dragged on in years and Paul never gave up.
He would constantly post lost dog outs around part of the country with the hope of someone
who may have found Damien.

(02:04):
Are you ready for this?
Last week, a woman from Oklahoma City nearly ran over a dog.
She got out, it was a bit shaken, she brought him to a vet.
They scanned for a micro-trip and you guessed it, it was Damien.
His family were en route to LA to help donate clothes to shelters from the wildfires when
they got the text of a lifetime.

(02:26):
After eight years, Damien was reunited with his owner.
That is an amazing story and a really good way to start the day.
Thank you, Kelly.
You're welcome.
Our first guest to talk about feeding cues and infants is Dr. Alicia Delgado.
Dr. Delgado has worked in early intervention for 16 years.

(02:49):
She's a speech language pathologist who specializes in pediatric feeding and swallowing.
Dr. Delgado obtained her clinical doctorate in 2022.
She provides early intervention trainings across the state on feeding and swallowing.
Welcome Dr. Delgado and thank you for being our first guest.
Absolutely.
This is a huge honor and a privilege and I love representing the amazing school of Rock

(03:14):
Chop J-Hawk.
Go, Kelly.
Well, Dr. Delgado, can you share with the audience how you became passionate about pediatric
feeding and swallowing?
It really started as a personal journey for me.
I spent the first leg of my career in the hospital as an acute care speech pathologist

(03:34):
in Tpeca area.
Coming out of grad school, my dream job was that acute care physician where the sicker
the patient the better is kind of how I was and enjoyed that period of my career.
And then when we were expecting our youngest or fifth kiddo, I developed a lot of severe

(03:56):
complications that there wasn't a whole lot known of what to do to treat.
So I spent a lot of time trying to stay pregnant long enough to give our youngest the best shot
possible, which led to her being born at 30 weeks gestation.
And mind you, this was my fifth child.
So my husband and I had experienced becoming new parents many times and lots of variations

(04:22):
of them because they're all five very different.
But we had never experienced a NICU journey or what it's like to be pre-neparents.
We ended up, you know, she is now 17 and a senior in high school.
So this is, you know, going back a bit, but we ended up needing to take her home with
the NG tube still in place because she was an awful theater.

(04:47):
We spent nearly two months in NICU and I had to get her home so that I could get back to
work because the insurance for the family under the time was under me.
So it was just a lot of life situations that led us to where we were at the time.
I had specialized in feeding and swallowing in adult geriatric population, head injury,

(05:09):
stroke, et cetera.
That neurogenic population during my acute care years at the hospital with some outpatient
and some fill and rehab, et cetera.
But it was all primarily adults with a little bit of Pete sprinkled in.
And what I realized during that journey is I didn't have a clue what to do to help my
own child.

(05:30):
And at that time, there was no SLP that worked full time in the NICU.
They just kind of would pop in.
There was one SLP at the hospital we were at in Tpeka at the time and she would help in
the NICU periodically, but for some reason we never crossed paths when we were there.
So I did the only thing I could think of and I whipped out my pre-feeding skills book that

(05:56):
had worn yellowed pages and lots of dust.
I could have beat somebody over the head with it, thick book.
And I sat in the NICU every single day, all day and all night with my husband, I chipped
her staying with her and I just read and read and read everything I could.
Now mind you, I had a very extensive background in feeding and dysphagia.

(06:21):
At the time, I had done thousands of video swallow studies at that point in my career.
I was trying to do fees and pass scopes on ICU patients on a daily basis.
So I mean, I had massive amount of training already, but I did not know how to help my
own daughter with developing her feeding skills.

(06:43):
And it was crushing.
The other thing is at the time we discharged home.
Again, like I said with an NG, we weren't told about the early intervention program
at the time.
I didn't know how to access it.
I barely knew it existed.
So we came home and it was just us figuring it out.

(07:04):
I went back to work.
Her NG, she pulled it out like lots of them do.
And my husband would page me 911 at the hospital and freaking out.
And I call him back, he's like, she pulled it out.
What do I do?
He'd drive her up to the hospital.
Like meet him down in the parking lot, put it back in, and then go back up to the floors
and keep working.
It was a journey.

(07:24):
And we still, I think, are working hard on understanding the amount of parental stress
and trauma that is experienced at no fault of anyone's that being a NICU parent is brutal
and just the experience that we live is hard.
And on the outside of the NICU, it continues to be that hard because everything we do,

(07:46):
we do is filtered through those early experiences.
So long story short, I continued to work at the hospital for probably about 18 months
or so.
And the grind just got to be a little too much at the hours and the pace of everything
with trying to help do the best we could for our daughter.
We did get her offer in G-Tube in a little over a month and a half, two months.

(08:11):
And she did transition to full feeds from the bottle at that point, but was never able
to breastfeed.
And I would argue it was just because I didn't know what I didn't know.
And I didn't have the tools in my toolbox at that time to know anything to do different,
which was a very hard thing for me to accept and swallow.
When I realized it was time for me to transition out of the grind of the hospital setting at

(08:36):
the time for the betterment of my family, I spent a lot of time thinking hard about,
what do I do next?
And that's a real pivotal stage in anybody's career.
And it really led me to back to that saying of, if you don't like what you see, be willing
to do something about it and make a change.
And so I reached out to the infant toddler program in my area at the time and just started

(08:59):
asking questions and saying, I have no idea if this is a fit for me, but I know what my
experience has been as a preemie mom and with all of the knowledge that I have and it was
brutal and I feel like maybe this is where I'm being called.
So we met and before I left that meeting where I thought we were just chatting, it was, we

(09:21):
would love to have you.
When could you start?
And so the rest is history.
Again, it's been a little over 16 years at this point.
And I have said many times you could take the girl out of birth to three, but you're never
going to get the birth to three out of the girl because so much of what I remember thinking
about my style of practice in the hospital just flat doesn't make sense to me anymore

(09:46):
after understanding the value of providing intervention treatment in the natural environment
or within the context of what is actually going to happen when you leave those four
walls.
So it has continued to be my mission to chip away and making a huge dent in the access

(10:09):
to services across in my area.
But then of course, you know, the ripple effect of branching out into getting it into all
the communities and all of the programs across Kansas.
Eventually it would be fantastic to know that we've made a huge dent nationwide because
these are the most fragile humans and they deserve our absolute best.

(10:30):
And part of going back to do my doctorate was how else can I forge a way to improve
the systems that we already currently have and in learning we really don't have, which
was an experience that I had as well.
We really didn't have a lot of access to pediatric feeding and dysphagia training and basic science

(10:53):
understanding in the graduate program.
So what I came to know through the study that I did nationwide was that that continues
to be a common thread across the country.
So it's just important that, you know, we got to start from the ground up and build
it right.
Thank you so much for sharing your story with us.
I think it's important and we're very lucky to have you with us today to be able to start

(11:16):
to help us build our knowledge as providers also to give us that kind of peek behind the
curtain that roll inside into what it's like to be a parent of a baby, a preemie.
So absolutely.
Thank you for sharing that.
Before we get started with our official questions, I was wondering if you could share with the
audience what a pager is because some of our listeners may not have that in their vocabulary.

(11:42):
Yeah, that's a brilliant idea.
And I am really getting used to these moments where people look at me with confusion on
their face and say, wait, what's what, what is that?
And I go, oh yeah, I'm not 20 anymore.
You know, back in the day, staff at the hospital would have a little black box that we hooked

(12:06):
on our hip on our scrubs.
And when someone needed me on another floor, they would call a number in my pager, we'd
go beep, beep, beep, beep.
And I would get a number and I would call them back.
So yeah, that was how everyone found me back in the day.
This is definitely pre-smartphone.
Nowadays if you go in, you'll see them with these little things on their scrubs where they're

(12:29):
just kind of talking to each other, word like a walkie-talkie.
But yeah, there was a phase in history when we got paged.
Well, and not even just, not even, you know, in a hospital.
I mean, if you were cool, you had a pager.
You had a pager and you called your friend from, you know, the pay phone.
I was going to say, nobody had a phone.

(12:50):
You stopped and went to a pay phone.
If you had a pager.
So right.
I was definitely never that cool because they were expensive.
Yeah.
Broke is a joke through school.
So I was never that cool.
As a matter of fact, I think when my husband and I had our oldest to give you context is

(13:12):
31, I remember him borrowing a pager from a friend of his so that if I went into labor
while he was not home that I can reach him to say, it's time.
It's time.
9-1-1.
Right.
What are some feeding cues in infants?

(13:33):
So here, some of the things that I feel like are the most magical moments in working with
families, but also with fellow colleagues and providers in early intervention and outside
of early intervention is having a lot of conversation around that we as providers often feel the
pressure to always have the answers in lots of scenarios.

(13:57):
You know, we are highly trained to figure out how to do comprehensive evaluations so
that we have some degree of professional confidence walking away of we figured out what was going
on with the patient or the person that we're working with.
And here's the news flash.
Babies, even newborns are absolutely brilliant human beings that can communicate exactly

(14:23):
what we need to know.
And the key is really learning how to interpret what they're doing and their communication
that they're giving us to understand what to do about it.
And you know, again, every SLP, ECSC, OT, PT, all the providers in early intervention that
I've ever worked with, everybody wants to do amazing work for these babies.

(14:47):
And the challenge is what do I do?
And so learning how to read the cues is a huge piece of that.
Some of the cues that even brand new babies are going to show us is centered in what I
like to call their midface.
So that's like nose up to forehead.
So even if the bottle or the breast, they're at bottle or breast, you could still or should

(15:12):
still be able to see a large portion of that midface to look for those cues, which could
look like their eyebrow raising or furrowing.
If they are getting a lot of nasal flaring, meaning I'm working really hard to breathe
here, I'm going to need a little support.
One of the earliest cues that baby babies have that they can implement and use in their

(15:34):
toolbox, even at just a few hours old is just to say, this is too much.
Good night.
And they just pass out and go to sleep.
A lot of times I think we're not always great at talking outside of our heads.
And I think sometimes that comes back to the fear of maybe what I'm thinking they're doing
is wrong.

(15:56):
And I afraid to be wrong.
But what's super valuable is talking and saying all of the things that you notice changing
in baby from beginning to end of feed out loud, because that's a very inclusive way
of getting parents to start seeing the same things and hearing the same things that your
eyes and ears are hearing as well.

(16:16):
Other big cues are what is their body doing?
What do they feel like in whoever's holding them and feeding them?
What's happening with their tone as they're eating?
If we start pretty calm and then suddenly we're firing muscles all over the place and we're
feeling a lot of tension in their body or they're trying to arch and kind of pull away,

(16:39):
those are all communicative cues telling us this doesn't feel good.
Because what we do know is when it's feeling good, it's timing itself well and all is right
in the world of I'm feeling my belly and getting ready to lull out to sleep.
Their body is calm and centered, their face is relaxed and they just kind of mold into

(17:02):
mom, dad, whoever is feeding.
So when those things start to change, then we know something's going awry.
If they start out not calm and centered and relaxed at bottle or breast, then often that's
telling us that it maybe hasn't been going well for a little while.

(17:24):
And they've already learned that this is hard for me and I'm really stressed.
Dr. Delgado, it sounds like you're wanting to build the capacity of the parents or caregivers
being able to recognize the cues and their infant.
And I can imagine that if the baby was born premature and the parents are sleep deprived

(17:47):
and just all that stress that comes along with that, that can be harder.
Parents are dealing with so many different things.
Also, if you have multiple caregiver, making sure all the caregivers are recognizing those
cues.
Yes, that's a huge part of what our work is.
And I think it's important to note always there is a large difference between what we

(18:10):
are focusing on oftentimes during NICU experiences with the goal always of getting out and going
home.
And so, there consistently is a high amount of pressure, attention, and focus placed on
finishing those bottles or taking, transferring a specific number of MLs, which is volume

(18:33):
in the bottle or at breast by when they before feed and then after feed to know how much
they transferred.
That is something that is spoken about probably 20, 50, hundreds of times a day.
I don't know, it's different for every family, but it is a constant thread of this is the

(18:54):
last big hurdle that must be jumped to get home, which every parent's goal is like,
when do we get to go home?
Those last several days or weeks can often be just as hard as the terrifying early days
and weeks because you're just sitting there waiting for baby to get the clear to go home.
And you just can't wait to get them home.

(19:16):
But what does often happen, and I see it over and over and over again, is that we train
our brains, which mine was trained the exact same way, to hyper focus on did they take
the full feed even once we get home.
So there is a big culture shift that early intervention providers are tasked with of

(19:37):
helping parents tune into their baby's cues and learning how to develop that back and
forth communication of I show you a cue and then we support family in trying some things
that we know typically could make a positive impact and not letting them stay terrified

(19:57):
if there's 15 ml left in the bottle, but it's 120 ml feed and pushing baby to go beyond
because they have been taught over and over again.
What really matters is they took every last drop of that feed versus that natural back
and forth communication between parent and baby.

(20:19):
So I do feel like that is a huge piece of empowering parents and helping them settle
into the joy of babies now home and figuring things out with their new little family, especially
you know, kids that have a lot of medical complexity feeding can continue to be very
hard and it is a very slow, thought a cool process forward.

(20:44):
I often talk about this as a marathon and not a sprint and for parents who have had
other feeding experiences, that's tough because they just had maybe a very different experience
the first time or two where, you know, they put baby to bottle their breast and then child
took off and it felt very different.
So I would argue that breastfeeding is hard even in the best of circumstances for a lot

(21:10):
of us and so the challenges can just be super duper complex and helping parents start to
feel like they have the knowledge of what can I do when my babies showing those big
stress cues of I'm struggling to coordinate my breathing with my swallowing so that at

(21:33):
10 o'clock at night they're not panicking and just stopping the feed because they don't
want know what to do and they're mostly terrified of hurting their child and the baby ending
up back in hospital.
So we really focus on talking outside of our brain and saying, you know, when I see that
it makes me realize that he's telling us I need a I need a breathing break.

(21:57):
I need to catch my breath because I'm going to really struggle to slow my work of breathing
down or this bottle might be flowing just a little too fast.
What is a simple thing you can do to slightly slow it without needing to change the whole
other system?
All of those things empower our parents to gain confidence and that they really are the

(22:19):
ones that know how to feed their babies the best and it's really important that they have
that information especially as some families are dipping in and out of the medical model
and having that confidence to be able to say like, we really do know the best methods for
feeding our kiddo and yeah, they, you know, their 12 o'clock feed tends to be the time

(22:42):
every day that they just don't tend to finish the bottle, but they really do make it up
later in the day and they're just kind of wiped at that time and to give permission
to say that that's okay.
What about premature and fragile infants?
Do their feeding cues like different?
Are they similar to what you described with the midface, some of that tone, things like

(23:05):
that?
Feeding cues, regardless of whether they're early or not, are often pretty similar.
The extent in which they may show them could vary differently and the length of time it
takes to really gain that neurologic wiring to be able to coordinate things on their own

(23:25):
often looks a little bit different.
Extra babies as a general rule for me often tend to need extra physical support longer
because these little bodies came out earlier than anticipated and gravity is brutal on
them because they didn't get a chance to develop the same muscle tone that their full term

(23:48):
peers would have.
So being able to get their body to pull to midline and center and organize is often much
harder for them and so some of those strategies and techniques of helping support their body
can last longer than maybe what they might for a full term peer that's just struggling

(24:08):
a little bit with swallowing for various reasons.
So it certainly can look different, a little bit more intense.
They may have more things that play as like thickening of feeds and stuff like that that
a full term peer may not have, but you can certainly have full term babies with cardiac
issues and difficulty with swallowing and other neurologic things going on that prematurity

(24:35):
alone doesn't automatically mean that they're going to struggle more than a full term baby.
Certainly a full term baby that's maybe had HIE or difficulty with getting full oxygenation
during birth and that has some degree of brain injury is not necessarily going to need less
than a premature baby.
So prematurity itself doesn't automatically equate more difficult feeding than another

(25:00):
child that we might be serving.
Thank you for sharing that.
Of course.
Now that we know what to look for, how do we as providers interpret those cues?
There is a long list of different cues.
I always encourage everyone to kind of look, listen and feel because you're going to, from

(25:21):
child to child, you're going to notice different combinations of those that will help us have
some degree of understanding of what would you want to adjust first.
There's several like very foundational impactful things to continually remember while doing
this work.
And that is that it's really important to do our best to try to make one change at

(25:45):
a time because what happens if we change two or three or four things because we're kind
of anxious ourselves and we're like, oh, maybe I'm forgetting about this or maybe they need
this or whatever the case may be that when you start changing more than one or two things
at a time, I really hesitate even making two big changes at a time.

(26:06):
What happens is what happens if it doesn't work?
What if it doesn't look better after you've made two or three or four changes?
You really have no idea what that combination of changes has impacted what fell apart for
them.
What could have worked if it was used just in isolation.
So example, a kiddo, you know, I go out and I'm watching a kiddo eat or I watch videos

(26:32):
all the time, colleagues send me videos all the time from that they take on their iPads
during visits.
And I'm really hyper-focusing on that mid-face and I always ask them to kind of pan out to
let me see what the whole child's body looks like.
And if I hear a lot of clicking and popping, it's a common one that everyone talks about

(26:52):
all the time.
Sometimes we like to, and more recently, which this could be a whole podcast and in and out
itself, so we won't go down this black hole, but sometimes it could be due to tethered
oral tissues.
And currently that is, I mean, if I had a dollar for every time.
He said, hey, Lucia, do you think they have tethered Joe?

(27:14):
You'd have a pager.
You'd have a pager by now.
I could have 65 pagers now that were plated in gold.
But could it be, of course, here's the one thing I'm going to say about this giant subject.

(27:34):
A lot of us walk around this world with ties.
I don't care unless it's creating a functional impact that the child cannot develop through.
The research does tell us that we need to try intervention first before we jump straight
to laser and cutting.
And it's not saying that I don't recommend it on a decent amount of basis, but it is

(27:57):
important that we don't throw out the baby with the bathwater in terms of treating that
population.
I have a tongue tie.
You'd never know unless I showed you.
There are various reasons of why you would intervene with that.
So I don't want to minimize that.
I just know it's a very polarizing topic.
It's an important one.
And at some point, maybe down the road, when it's no longer the major main voyage, we maybe

(28:20):
do a full hour just on it.
Absolutely.
Yes.
That is a huge topic.
It is a huge topic.
It's really important to understand the science behind it.
But back to the clicking and popping.
It could be that there's a tie there.
It also could be that your baby is just super smart and has realized that every time I draw

(28:43):
to get that suction going, I'm pulling way too much volume because the flow rate of this
nipple is not a good match for my oral motor developmental age.
And I'm relaxing to let some go.
Clicking and popping is always a negative thing because every time they do that, they're
pulling little puffs of air and then we're putting a ton of air in babies' belly and

(29:08):
intestinal system.
So when I hear that, I always ask parents, do you feel like your baby's gassy and fussy
a lot?
And again, if I had 50 cents every time they looked at me, I was like, yes, with this look
of desperation, like nobody's getting that.
There are these beautiful little moments where sometimes you just get to walk out feeling

(29:31):
like you're 12 feet tall because these parents are like the babies throwing up all over the
place.
They're gassy and fussy all the time and all of these, they're not sleeping well.
We get some of that stuff under control and we reduce the amount of clicking and popping
that's happening and so they're not taking as much air into their system.

(29:52):
You'll naturally see improvement over time of constant vomiting, constant periods of
gassy, fussy babies who are losing their mind all the time and then it has positive impact
on sleep.
So that's just one really good example of an easy fix.
And I say easy because it stands out like a sore thumb and you hear a popping clicking

(30:15):
baby, you can't unhear that.
Position makes all the difference in the world.
When I do my trainings, I'm constantly asking the audience and those attending to say back
to me, what's first?
What do we do before we change anything?
And it's always going to be position, which is a beautiful thing that we have an early

(30:36):
intervention that most settings don't have access to and that's the amount of collaboration
and co-treatment and supporting and training each other in understanding what to do in
the field and bringing out your PT and OT while you're trying to gain those skills as
much as you can or sharing video and coaching each other is again why you could never get

(31:01):
me out of working in that birth to three mentality because positioning is a game changer.
You know, it's one of those things where a baby is not in ideal position, their neurologic
system cannot get organized and centered to focusing on what their mouth needs to be doing
because we're out here managing ourself in space.

(31:23):
A colleague that I work with has a great saying, sometimes in early intervention, we can feel,
let's say, a scoosh-frazzled.
And in team meeting when we come in and we look at each other, we're like, did you feel
like the windsock in front of the car dealership right now?
And she has coined that as wacky wavy.

(31:45):
So if you're feeling wacky wavy, now I'm going to have to totally say that I brought this
up on the podcast and that is a Sarah Greer phrase.
So I got to give her credit where credit is due.
If the kiddo during feeding is looking like a wacky wavy, they are not organized and their

(32:06):
mouth will be a disaster.
So supporting that body is what you will see, but then the feeder also feels that.
The reason we don't take babies from parents and feed them and get them looking all pretty
and then just sit in the feeding, because all that does is really reinforce to mom and
dad or the daycare provider or grandma, whoever is, I can't feed my baby, but somebody with

(32:31):
all this knowledge and experience can and it gets a horrible feeling.
So if we need to feel it, sometimes I'll reach over and put my hands on the end of the bottle
so that my sensory system is getting some input, but I try my absolute best not to take baby
out of parents arms ever.

(32:51):
And I'm sitting beside them next to them making those slight adjustments.
And as we get something adjustment, I will then say the things like, okay, now do you
feel that difference?
What is your body feeling?
Let's talk out loud about what does that feel like to you right now compared to what it
felt like two minutes ago.
And then you'll see parents' shoulders start to relax and their body starts to relax.

(33:15):
Those are those critically valuable things that we do in early intervention that help
parents understand what does the popping and clicking mean?
What does it mean when their babies' body looks like a wacky wavy?
Does their eyebrows start slowing down from like, you know, up and down their forehead,
like they're running a sprint?

(33:35):
Do they hear loud gulping?
If we hear loud gulping, they are squeezing with clear to their toes to try to keep that
milk going the right direction.
So those are some of the cues that we might hear baby doing that we can explain to parents.
What does that mean?

(33:56):
Instead of just saying, oh, they're kind of loud.
Well, that's not really helpful because that doesn't tell them how to interpret that when
they hear it again when you're not there with them.
So if I do think the bottle might be flowing a little fast, like we hear those loud hard
gulps or high pitched hard swallows, I may ask to interrupt the feeding and take the

(34:18):
bottle because there is a quick little on the fly cheat that you can always try before
you jump straight to, oh, we need a whole new nipple.
And that is, I always want to feel how tight the collar is.
A lot of people call it a ring, but the ring or the collar is on the bottle.
What's their bottle feeding?

(34:38):
If it's on hand tight, which truly is how all bottle systems have been developed is
the collar should just be hand tight.
But if it's just hand tight and I feel like I've got a little bit of a half crank that
I can do on that, I would try that.
And then we'll go back to feeding and see if any of that hard swallowing starts to relax

(35:02):
because that's a way to slightly slow the flow of any bottle.
If it improves, but it doesn't completely resolve or enough that I feel comfortable with it,
then that is one of the things that I would say out loud.
And you know, this is a way we can slightly slow your bottle and it looks a little better,
but it still seems like your little one's struggling some.

(35:24):
We might need to look at trying a step down.
This may be flowing just a skosh too fast.
So let's look at that and try.
Same thing is when you go out and that bottle nipple is collapsing, they're over sucking
and parents are afraid to move up to the next blow because feeding maybe has been hard and

(35:45):
now they were finally doing well and then suddenly the wheels came off again.
And if they're over sucking the bottle, one of the things that I watch for to know whether
baby's over sucking the bottle is right at the creases of their lips.
So we call it the nasal labial fold, fancy term for like the quarters of their mouth.
When they get a lot of dimpling and puckering there, that's one of the cues that will let

(36:09):
you know they're really sucking with all their might to try to pull through the nipple.
So they may be ready for a larger or a faster blow nipple and parents are just afraid to
move it because it was going so well for so long and it's like nobody in the room moved.
We finally got it.
But they'll get to a point where they develop through that.

(36:31):
So if I see that, one of the first things I do is ask to see the bottle and I will see
is this color on really, really tight.
And if it is, especially if dad made the bottle, dads are notorious for this.
I will relax that color and then put it just hand tight and then go back to feeding.
And if it improves, then we have that conversation of, I know you're a big strong guy, but let's

(36:58):
relax that color on the bottle and note like, look how much progress your kiddo has made.
They're now developing such a strong suck that cranking it on hard like that is frustrating
them and they are over sucking that bottle.
So we're probably going to be looking at bumping up, but not yet.
That was a lot of great information.

(37:19):
A lot of strategies, things for us as providers to think about in that feeding realm.
How do we know as providers when we need to bring in another team member to support us?
You mentioned positioning and having that OT and PT.
What are some of the things that you help you to decide when you need to bring another

(37:42):
team member on?
Again, I think it's going to vary from person to person because if somebody is newer in
their journey of learning the different sides of early intervention because we are early
intervention at this, who also happen to be ECSCs, PT, OT, SLP.
So we have our area of expertise, but we all need some of that skill set in all areas to

(38:08):
be able to, like you said, Leslie, identify when something's not quite where it needs
to be yet.
And I have enough knowledge to know we need to get our expert out here and help put our
brains together and figure out the just right things this kiddo is saying we need.
I really encourage everyone again to have lots of conversation as an SLP with our motor

(38:34):
providers or the people in your network that tend to excel in that area because if positioning
isn't going well, the feed will not go well either.
So those are kind of easy breezy ones to know like, oh, I need to get my motor support person
out here so we can make sure that we're getting the positioning just right.

(38:55):
And this isn't just an infancy.
Transitioning to breast and bottle feeding only into complimentary foods at around six
months of age is a time that, again, we tend to lean pretty heavily on our motor support
people because we're looking at modifying pie chairs and things like that because the
same holds true when we are trying to transition to solids, that positioning has to come first

(39:21):
or the mouth will be a mess.
So those are really key times to look at having that motor support if you're not the motor
person as a motor person.
If you're the one doing the FSC and the primary work and you're like positioning looks great.
This still does not look like it's going well.

(39:42):
That's a really good time to bring out your person in your network who is the one with
more feeding experience to say, I need another set of eyes because these are not easy kids
most of the time.
They're pretty complex.
A lot of the ones that have medical complexity are, I like to call them all hands on deck
kids because as their body changes, our strategies and interventions need to change with them.

(40:08):
And what we're doing at one point may be not the best fit for them down the road as their
body is changing.
I think teachers are amazing at doing the all hands on deck approach and keeping us all
really focused on why are we here today so that we don't get lost in our little silos

(40:32):
and stay out of the silo as much as you can because if you live in the silo, you're missing
a whole lot of stuff.
And from a feeding specialist standpoint, there are definitely times that I've leaned
really heavily into my teachers when we're working on transitioning the solids and or
OTs and teachers together.

(40:53):
The sensory transition is really, really hard.
That's a great time to get some help with developing their pretend play and thinking
of creative ways to try to get them engaging with foods differently than maybe they would
instinctively come up with on their own and doing a lot of out of the box thinking.

(41:16):
Dietitians can be incredibly helpful as well.
That is one thing that I do hear often from different providers in different areas of,
I don't know what to do about these numbers, especially with YouTube fed kids.
One of my encouragements that I always offer is that COVID really changed our world a lot.

(41:41):
But one of the positive things that has come out of that is that we can coach parents to
access their dietitians that they may have with a lot of their specialty teams through
Children's Mercy and other medical networks to be able to gain some of that information

(42:05):
in a way that we couldn't before because they're so hyper-connected through their portals now.
So even if you don't have a dietitian on team, you can talk through with the parents.
So here are the big questions we have.
Have we made enough progress that they might be able to reduce the volume or are we just

(42:26):
doing what we're doing until you go back in six months to see the next specialist?
And before that would have held us stuck for a really long period of time, right?
Because you don't have access to a dietitian.
It's out of the scope of any of our practice unless you're a dietitian.
So now we're realizing like parents can ask those questions and they don't have to wait
until that six months follow up.

(42:48):
So that's another really good thing to think about is you're trying to help parents navigate
the access that they do have.
Yeah, that's a really great point.
Talk to us about the motor planning theory.
Why is this important?
That's a great question.
The motor planning theory is that understanding of the amount of experience and exposure any

(43:13):
of us need to go from we have not gained a skill to working towards gaining a skill,
not just gaining but refining for mastery.
And this one holds true in all areas of life.
And for feeding specifically, a great example is, you know, it's very it's part of typical

(43:36):
development for children around 12, 13, 14 months at age to experience some degree of
gagging as they start that transition onto full table foods.
And part of that is because they're trying to learn how to control the bite.
We call it a bolus in my world of keeping it in the space where it needs to get broken

(43:57):
down before they're ready to transition it back to trigger and fire that throat or pharyngeal
stage of swallow.
So as they make that big transition, kiddos will experience those moments of where they're
like, and they have that little gag.
And that's just, oh, it fell back there before I was quite ready to pull it together and

(44:19):
fire that swallow.
So in terms of the motor planning theory, when we're working with kids that are struggling
or having challenges with gaining those feeding skills, a lot of times family service providers
will ask me as I'm consulting with them, how long should we do that and then move to the

(44:39):
next phase?
And I always encourage us to go back to thinking about, well, what do we know about the motor
planning theory, and that is that it takes one to five weeks of experiencing something
before you're ever even getting to what we would characterize as the beginning of refinement.
So how do you use that clinically?

(45:01):
If you have a kiddo who's really had a difficult challenge with feeding and gaining some of
those skills, they may be a little bit older than their peers when they're hitting some
of those big changes in the feeding journey.
So we might not have been six months when we started experiencing purees for the first
time or any kind of complementary food for lots of different reasons.

(45:25):
We could be 18 months before we get to that stage.
Obviously, that's not what we want to do, but for medical reasons and various reasons,
that can be the case, especially for kids I see.
So we're not going to expect to just have exposure for one or two weeks and then it
magically start looking better.
We're going to need to remember that minimum five weeks before we start to see maybe they

(45:49):
figure out how to keep their tongue in their mouth instead of shooting it straight out.
Because we know the first motor pattern to develop is the forward and back kicking of
the tongue, the central roof, so that the size of the tongue come up to meet the palate
of the mouth.
That's how they transfer their milk volume from anterior to posterior in the mouth.
So it is stance to reason that when we transition to something other than milk, what we see

(46:14):
that tongue often do is shoot straight out of their mouth.
And the question is, well, how long will we be doing this like a refeeding where you
scoop that little bite back up and put it back up in their mouth?
It's probably not going to take just two or three weeks if we're doing it at a much older
age.
If we're doing it at a much older age, we know that there's a lot of other stuff going
on.
So just keeping in mind that our recommendations and coaching of each other, we have to remember

(46:40):
kind of some of those basic scientific principles that we're not setting parents up to feel
like, why is my kid not getting it when other kiddos seem to be doing this so much better.
And helping them feel comfortable with allowing their kiddo that same grace of the amount

(47:01):
of time that it really takes for that neural wiring to set in and then refinements to start
happening before we would expect them to master it.
It does allow parents to celebrate their child's progress much more fully when they realize
that they're just going the typical developmental process.
It just happens to be happening at a later age for them.

(47:23):
And I always like to remind parents because most people I don't think really know this
and even as developmental specialists, it seems to be newer information often.
And that's that feeding development maps us out at the age of three, meaning in typical
development by the time our child is turning three, which is when we have to transition

(47:46):
and let them go with all things that have gone beautifully in rights in the world.
And they followed the progression of all of feeding development by the age of around three
or a little over, they have developed all the skills they need for healthy lifelong
eating.
I hold that in my pocket, especially for parents who, man, they've really had a hard journey
with their kiddo.

(48:08):
Even if they're two and a half and they've transitioned on to purees or whatever the
case may be, I like to let them know of, you know, the difference in feeding development
is when your kiddo is four or five or six years old, they don't have to make up development
from 12 months to six.
You're only shooting for that development to hit that max developmental stage of about

(48:32):
three.
So as they age, that gap doesn't get bigger.
And we really can't always say that in all the areas of development that we have.
So I do feel like it's a very loving and supportive thing to help parents realize that that gap
isn't going to get wider and wider and wider because you're only shooting to develop up

(48:52):
to that age of three.
So the motor planning theory can be very helpful in meeting those conversations with your colleagues
because colleagues can get just as discouraged if they don't feel that progress is happening
and then it turns into what am I doing wrong?
And oh man, I feel like I haven't done enough or I wish I would have known how to help this

(49:14):
family better because none of us do this work without loving it with a passion.
And showing up every day wanting to make the biggest difference in these little human lives
that we can.
So it's another thing that can be very supportive of our colleagues as well to help them remember.
We've got to be fair and we've got to allow them the same amount of time that we would

(49:37):
allow their peers.
So you're looking at like 12 weeks before a skill would be considered practiced and
refined enough to hit mastery level.
And that's all things going well, right?
So if we have other complexities like muscle tone and things like that, it's reasonable
to say it could take longer than 12 weeks.

(49:59):
Wow, that's great information.
I did not know that.
Mind blown, right?
I feel smart.
I mean, I do too.
I do too.
Yeah.
Thank you.
One of the happiest moments for me is when I see people's faces go, wait, what?
And they're like, I never knew that.
Yes, I did not know that about the age three and you have all the skills you need.

(50:24):
So that's great.
Well, that's what you can use to really support your parents at the highest level possible,
right?
Absolutely.
Absolutely.
Well, thank you so much for being our first guest on this meeting voyage of the Early
Intervention podcast.

(50:44):
We really enjoyed having you.
It's been so fun to talk with you as we wrap up our time together today.
Is there a tip or a strategy that you would want to leave providers with?
Yes.
But there's some of my favorite little, excuse me, key phrases that I like to keep on the

(51:06):
table and remind people about often is when we're looking at babies and watching them
feed.
We have to remember that as human beings, regardless of our age, if you can't breathe,
you can't eat.
We breathe and we swallow down the same channel until right before it gets to that upper airway
or larynx area and then the esophagus.
So if a baby is working really hard to breathe, we really got to look at how do we support

(51:31):
that before we expect the feeding to go better?
I think I already said, position is everything because it is and every PT and OT out there
just lights up like a Christmas tree when I'm leaving with that.
They also love my other favorite saying is SIDMO, which is sensory input, drives and
output.
And there is a ton of signs behind that, but just keep reminding yourself that the sensory

(51:55):
input does drive the motor output.
My last big example and tip or trick to think about with that is thinking about a newer
nipple that I'm seeing often coming out of NICU babies or some breastfeeding recommendations
with bottle drinking is happening with this too.

(52:17):
And it's a current trend with something called a MAM nipple.
And the MAM nipple is one that babies access the milk through use more of a compression.
So we're more up and down, lunching on that nipple versus generating a sock.
And it tends to encourage that tongue to stay a little bit flatter in their mouth.

(52:41):
And remember I mentioned before that the way typical feeding around breast or bottle is
that they curl that little tongue up around the nipple and they form that central channel
down the middle of their tongue.
So that curling of the sides of their tongue up around the sides of the nipple to come
into contact with the palate of the mouth is part of the key of them generating the

(53:05):
pressure exchange of pulling and expressing the milk from mom's breast or the bottle.
And when we have a bottle nipple that encourages that tongue to stay flat and low, then we
can become pretty inefficient eaters at breast or bottle.
And when we're itty bitty, it's not always as big of a deal.
They're still able to transfer some, but as we grow and we need to take more and more

(53:28):
volume and we start moving with all our motor development, it is common to see Kettos kind
of fall off the edge of being able to take the volume they need for good healthy growth
and development.
So we have to work kind of hard sometimes to try to make that shift of getting them
onto more of a rounded nipple.
And again, parents are doing whatever they can do to survive out here.

(53:51):
It's the wild, wild west when your baby will not eat enough and they're not sleeping and
if baby is not happy, nobody's happy.
So I totally understand how we get to using that, but as providers, we want to remember
that at some point it may become too difficult for baby to transfer enough volume efficiently

(54:14):
to be able to grow at the rate that we hope that they would.
And sensory input drives motor output.
So if the sensory input to the tongue is broad and flat across their tongue, they're going
to develop a low flat tongue.
If the sensory input is provided more at the central groove of their tongue, it's going

(54:35):
to teach those muscles to fire in that motor pattern that creates more of that central
channel and develop more of a true suction versus munching.
So we could talk for 12 more hours about this, but...
Well, and we're going to.
Obviously, we have some more to talk about, and then we really thank you for joining us

(54:59):
today.
As part of our podcast, we really want to highlight someone or something as it relates
to early intervention by giving them a shout out.
Yay.
Yay.
So today, our shout out goes to all infant to all their programs across the state of
Kansas.

(55:20):
We want to recognize all the important work every early intervention program does to support
families through parent education, promoting child development, and strengthening parent-child
relationships.
Yes.
Well, Kelly and Dr. Delgado, that's a wrap on episode one of the Maiden Voyage on the
Early Intervention podcast.

(55:41):
We hope you enjoyed it.
Episode two titled Speech Language and Football, we will be speaking with Meredith Woodring.
She's a speech language pathologist, and Meredith will be sharing information with us on speech
and language disorders and a little bit about growing up with an NFL legend.
Look for episode two to drop on April 1st, and you can listen to the Early Intervention

(56:02):
podcast on Spotify, Apple Podcast, and YouTube.
We want to know what topics you're interested in hearing about on this podcast.
Additionally, if there is someone or something related to early intervention, you'd like to
give a shout out to email Kelly and I at Early InterventionPodcast at gmail.com.
We want to thank the infant toddler services alliance for their support with this podcast

(56:26):
and advocacy for early intervention in Kansas.
Visit them at itsofks.org to learn more about their work.
Well, it is time to say goodbye, Leslie.
Thank you, Kelly, for being a great co-host.
Until next time.