What I Was Missing in Feeding Therapy: ARFID, Airway, and Myo with Samy Hernandez

I was so excited to be back on the podcast because I've learned so much that I think a lot of SLPs, a lot of clinicians don't know and don't know the importance of knowing this knowledge about both feeding and myo. I remember this moment so clearly when I felt like my stomach just descended into my butt because I realized all of my kids, every feeding case, Had the droopy face, the open mouth, the weak and unstable jaw. All of them did.

Today's guest was in the very first CPFT Certified Pediatric Feeding Therapist cohort, and she's back to tell us what she's learned since. Spoiler, she thinks feeding and myo were never two separate things. Sami Hernandez is a speech-language pathologist specializing in pediatric feeding disorders, orofacial myofunctional disorders, autism, and receptive-expressive language delays. She's a Certified Autism Spectrum Disorder Clinical specialist and provides neurodiversity-affirming child-led therapy where connection is built through trust and play. She was among the very first cohort of SLPs to become a certified pediatric feeding therapist with a passion for safe feeding, expanding food repertoires, and making mealtimes enjoyable for the whole family. She has extensive experience with oral motor delays, OMDs, G-tube feedings, complex sensory needs, and dysphagia. Helping kids discover new foods through play and curiosity and improving airway, sleep, and oral rest posture is why she loves what she does. Welcome to the Untethered Podcast. I am your host, Hallie Bulkin. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner, and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up-to-date information in the orofacial myofunctional therapy, airway, tethered oral tissue, and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thanks for being a loyal listener.

As we jump into today's episode, remember To listen with correct oral rest posture.

Tongue up, lips closed, teeth apart. Breathe through your nose. Let's get started. I am so excited that you're back here. Last time we talked, you were fresh out of CPFT, and I know there have been some changes since. So let's just dive right on into it. What, what has changed in the last year?

What hasn't changed? So much has changed. So I remember exactly where I was when I last spoke to you on the pod. I was on Long Island. It was a month before I got married, a month before I uprooted my life and moved to Philadelphia. First time living in a city, first time navigating public transportation as part of my daily routine, going to a new private practice, then adding in some county work. So much has changed. It's my first time living in a city, being here. I work at a wonderful private practice where I am practicing feeding and myofunctional therapy. On a daily basis. And the biggest thing that's really changed professionally is adding myofunctional therapy into my everyday practice. Like you said, last time we spoke, I was fresh out of the certification with you. So I really said to myself, feeding is my thing. Pediatric feeding therapy is my thing. That's what I'm going to do. That's what I'm going to specialize in. Myo is a buzzword, but that's a separate beast. I'm not touching it. I'm going to let other people do that. And that only got me so far. And I started slowly realizing, hey, there's something fundamentally missing from my practice. I think it's Mayo. I need some guidance. I worked really closely with my supervisor here in Philadelphia, and she helped me figure out how I can introduce myself to Mayo. She specializes in Mayo, so I was observing her a lot. I still do. And then I started to learn what I didn't know. I'm seeing what she's doing, seeing, hey, a lot of her kids are similar to mine. I started to take a course and I learned about the open mouth posture, the low and forward tongue. And I felt, I remember this moment so clearly when I felt like my stomach just descended into my butt because I realized all of my kids, every feeding case had the droopy face, the open mouth, the weak and unstable jaw. All of them did. So it was a really big change to start to add this other beast, this myofunctional therapy into my practice and how that's elevated my pediatric therapy caseload. It's been a wild ride and it's only the beginning. So it's all good. It's really fun.

I love that. Now, so did your caseload look the same before as it does now? You just now have this second additional, not second, but additional modality or lens through which you can look at How your kids are presenting?

It's a different lens. Yes. For example, I remember when I got a pediatric feeding case, he's around 8 or 9, and he was diagnosed with ARFID. And mom really wanted me to address ARFID. And I was like, great, I'm going to get the comfort scale and the food helpers. And that's all great, right? Those are all great strategies. But I felt like I was only addressing what was handed to me. Mom said, here is ARFID. Take what you know about ARFID and please help my son. And I did. But what I was missing was the malocclusion. I was missing the high vaulted narrow palate. I was missing that the tongue was pretty rooted to the floor of the mouth. I was missing that he wasn't getting deep restful sleep and that he had a diagnosis of ADHD as well. And I thought, well, there are all of these components that I have been letting other professionals address instead of asking myself, well, what can I do? What am I missing? And I realized if this kid can't breathe, then we're not going to progress that far with feeding therapy. So what ended up happening was I was addressing the ARFID. I was working with the comfort scale, the food helpers, food chaining, SOS, incorporating all these different techniques into my practice. And then mom and I and my supervisor were talking about how the tonsils are enlarged, his tongue is pushing low and forward. We need to be able to breathe first. If we're struggling to breathe, then everything else that comes after is going to collapse. Breathing is that foundation. If we can't do that, we're not gonna see much progress anywhere else.

Airway first.

Yeah, very first. And I remember telling mom the first time I met her, hey, so I noticed that we have some malocclusion? What's the story with his dentist? What's going on? And she said to me, this is a lot for me. I just want to focus on Arfid. And I saw mom from where she was coming from, and I felt I didn't want to overwhelm her. So in that moment, I just kept going with Arfid.

Mm-hmm.

And something that I've learned throughout this year is parents are coming to you for help.

Right.

So it is okay to say, I hear you, and I don't want to push you. But I think it's important that I give you the information I have so that way you can make an informed decision about your child and how you want to best help them. And that's something I've learned. I think part of clinical growth is becoming better at having difficult conversations right then and there and not waiting and delaying. Because when you wait and you delay and you avoid an uncomfortable conversation, then you're Delaying progress. And you don't want kids to be in therapy forever. You want to address the root cause of things and then get them the help they need so they can move on and have the best life that they can.

Yeah.

Yeah.

No, I love all of this because I feel as a feeding therapist first, I felt like I was missing a lot through that myo lens. Right. And once I took the myo course, which I felt like was easier for me to understand having the feeding background, I was like, oh my gosh, this is another layer to the onion, if you will, but a really critical one. Because like you said, if we cannot breathe, That's the foundation, we're really not going to make a lot of progress in these other areas. We can't breathe, we're going to struggle to chew, swallow, breathe while we're chewing. But just, there's all— and if there's not enough room for the tongue, if we can't lateralize our food from one side to the other because the tongue's restricted, or there's just not enough space, right? So it's all these different things that can be going on that my brain had the same reaction. I was like, I remember this back, I took my course in 2017, I was like, what?

Like, whoa. Yeah.

What is that? Why did nobody teach me this? Why am I just finding out about this now? I don't know, I was probably Let's see, I graduated grad school in 2009 and this was 2017. So I was like, why am I just learning about this 8 years into my career? Like, why has no one ever mentioned this to me besides a friend I was having coffee with who said, oh, I took this course and it's changed how I practice. And I was like, and with my speech sound kids, I was like, wait, what? Pump the brakes. You can help this. I was like, I want to know. I want to know. And so from her perspective, that's just how it came about in conversation. She wasn't doing full-blown Mayo per se, but she was using it as a tool in her toolbox.

Yeah.

through which she was seeing these kids through a new renewed lens. And she was like, the kids are making a lot more progress because I'm taking an added myo approach. And I was like, okay, I gotta learn what you're talking about. So yeah, the rest is history, right? The rest is history.

I'm so glad that's relatable because I remember like a mean part of myself was getting down on myself for not seeing these things earlier and thinking, no, I've been working with these kids for 4, 5, 8 months and I'm now learning the root cause now. And why didn't I know that before. And I don't know, like, it's nice to talk to you because I feel like it's so relatable since we're in this field where you're constantly learning and you're constantly growing, and you shouldn't be expected to just know everything right off the bat. And that's kind of how I felt when I first started with Mayo.

Totally.

Like, why didn't I know this when I first started with these kids? And I felt bad. And then I realized we're all learning, and as long as we challenge ourselves to keep learning these things and asking the right questions and working alongside your peers and reading and taking courses. As long as we're doing these things, it's okay to forgive yourself for not knowing what you didn't know.

100%. And I think it's also one of those things— I'm actually— so I'm writing a book right now called The Integrated Therapist.

Are you?

I am. And I'm like 68 pages in. I was just telling my team, I was like, guys, I'm Starting chapter 4, I was like, can you believe that I've been so consistent? So I ended up hiring, I hired a team to help me. And so I have an editor and anyways, so I submit 20 pages at a time, which for me has been like roughly a chapter as we go. And then things expand or shorten or whatever. It's been such a great process, but I literally have to put a call in the schedule. And that's what gets me to submit my pages. I'm like, oh shoot, I got to sit down and work on this. Or I got to build time in. And as a neurodivergent individual, you can't force yourself to sit down and write, but they have some really great strategies for busy. people that works really good for my brain. And so anywho, why am I even telling you this? I was literally, before we recorded, I was sitting here editing chapter 3 and talking about the integrated care model that I'm writing about. And I don't want to give out too much information, but it was all about— my editor said, well, why do you think this is? Why do you think most people don't actually integrate care? And I said, because we weren't taught to. No one actually taught us this.

Yeah.

So it's not the fault of the therapist per se, or the other medical professionals. We are at fault of the medical insurance industry and how they dictate things need to be done. And so it really falls back on us to figure out, hey, this is not working and we need to have— we need to find a solution, right? And so anyways, it's that whole integration of things. And also, I think there's something to be said about once you do realize that there's more to the picture, being open to that, being willing to learn.

Yes.

And being willing to be proven wrong, right? Because it can hurt our ego a little, right?

Oh my gosh, yeah.

Man, I feel like there were so many kids I could have helped. And I remember coming back and saying to my families, I just got back from this really amazing 4-day training. I see some things differently. I want to share them with you, but first, would you allow me to evaluate your child? I'm not going to charge you. We're just going to do it in a normal session because this is a new skill for me. One, you're going to give me the opportunity to practice. Two, I'm going to see if I can help your child in other ways than what we've been currently doing, build on that. And Every— it was like 8 parents I offered this to out of the 25 kids on my caseload, and they all were like, yeah, absolutely, something to help my kid, go right ahead, here you go, right? And so I remember evaluating every single one of them and coming back and being like, okay, there's a reason why our mouth is always open and we're drooling. There's a reason why we are stuck on this speech sound. There's a reason why this child's not progressing in feeding therapy. There's— there was just every single child Every child, I was like, edit, picture, like play bulb's going off.

Yeah, you're reminding me about the speech hierarchy and how when I graduated from grad school and I went right into the field, I started with early intervention and I was given the speech sounds and when they developed. And if I receive a 3-year-old, for example, who doesn't have certain sounds and they're later developing, then you wait. And I was told, I was taught the wait and see approach that was ingrained in me because the county wouldn't cover, because the county wouldn't cover services that were being done if the child didn't need them until later on.

Mm-hmm.

So I went into, so timeline was I saw you in April of last year. I got married, moved to Philadelphia in May, and then I started at this private practice. I came in with all of this knowledge and I realized that I was doing a lot of waiting. I was saying, oh, your kid doesn't need therapy now because they're 3 and they don't need these sounds until later. Your child is sucking their thumb, but we have to wait until they're older to address it. There was a wait and see that was ingrained in me, and I don't think it was because I was a bad clinician or there are bad clinicians out there who do this. I think it's because that's genuinely what we were taught right out of grad school. 100%.

Yeah.

So I remember in December I had a sit-down with my supervisor, Regina, who I really appreciate her doing this. She sat me down and said, look, you are working for a very reputable private practice in Philadelphia. I need you to kick into high gear. There's no more sitting and waiting. You need to identify, you need to learn more about Mayo. This is a very airway, sleep, feeding, articulation-centered practice. place that we work at. So you need to identify what you don't know, and you need to start making changes. And I was like, I love it. Received. And I started observing her. I started shadowing her almost every day for a straight month as I was building my private caseload. I started taking TalkTools courses. I really did— I put in a lot of work, and I don't intend on stopping anytime soon, but I did put in a lot of work and realized we don't have to wait. In one of my courses, in one of the MyoTools courses I took through TalkTools, Robin Merkel-Walsh showed us a video of a 2-year-old speaking— a 3-year-old, I'm sorry, a 3-year-old speaking in sentences with every speech sound.

Oh, that's cool.

It's possible. And then after the video, she's like, so I ask you this, why are you waiting to address things like S and R and L and T when we have a tongue thrust? Like, why are we waiting? And I just sat there, oh, I'm doing everything wrong.

No.

Yeah. Yeah. It was, it was such a, I feel like December, January of this past year has really been like a huge shift, a big turning point for me.

For sure.

I just wish more kids, I wish more speech therapists and more professionals knew that we didn't have to Wait, we don't have to wait to address speech sounds.

You don't have— there's that. And on the other side, and I don't know where you stand with this, but I would guess that Regina would maybe agree, a little spicy here, but my hot take on phonological processes is that they're often not a thing.

Yes, yes! Why?

Because we often fail to look at the motor side of speech. And so I don't really— I think they're descriptive labels that we created for patterns that were observed in speech. I know ASHA currently has a definition around them, and it's a whole thing and all that fun stuff, but a kid doesn't have a tiny little fronting process living in their brain, right?

Right.

Take cat for cat, for example. We label that velar fronting because the K became a T, right? The /k/ became /t/. But what does that label tell us? The child produced an alveolar gesture instead of the expected velar gesture, right?

Yes.

It doesn't tell us, was the problem phonologically represented? Was it motor planning, motor control, lingual differentiation, timing, stability, sensory motor mapping? There's so many things that could be, could be going on, or a combination of the above. And I just feel now, following Dr. Moore and some others, speech motor research is showing us that some patterns traditionally classified as phonological are actually associated with measurable articulatory or motor constraints. And so I just— we could yak about this all day. I don't want to go here for endless amounts of time, but I think just the point is we're waking up and we're starting to see things differently. Now, not everybody in the speech community agrees with us, and that's okay. But in my opinion, you cannot call it language-based until you've ruled out motor. You cannot diagnose ARFID until you've ruled out a myofunctional disorder, an airway disorder. Yes, are there components? of ARFID that may show up in a case? Absolutely. But I think calling it ARFID as a primary cause can also ignore some of the other things going on, and we're not going to make progress using an ARFID, a traditional ARFID approach.

Yes.

That's not the root issue. And I'm not saying it doesn't exist. I'm just saying I thought the way I was taught was we can't diagnose ARFID until we've ruled out a motor issue, an airway issue, like all these other things, right? So I just go back to, I think we need to be doing more like integrated assessment and coming together as various professionals looking through various lenses, bringing our lenses together and really having a conversation as to, well, what did you see? This is what I saw. And us coming to the table with all the signs and symptoms and going, huh, well, now that we have all this information integrated together, what do we think the best individualized approach is for this child, right? Maybe it is ARFID, maybe it's not. Maybe it is more of a language-based disorder, maybe it's not.

Mm-hmm.

Anyways, like I said, we can go on all day, but I just— so many of the kids that I saw getting stuck in therapy for endless amounts of time, not making progress. So they make a little progress, hit a wall for a while, make a little more progress because we switched something up, hit a wall again. When we started looking at structure and how it impacted function and airway and all these things, I was like, huh, every single one of them, at least on my— Every one of them. Every single one of them. had something going on that had not been addressed because I wasn't trained to see it yet. Right. And once I was, the rest is history.

Yes. And I came into my new setting in Philadelphia with that understanding that I was missing a lot. And I'm so grateful that I work at the job that I do. I work at a private practice where I work with so many occupational therapists that have taught me the importance of retained primitive reflexes. And how that could be harmful to something like feeding and airway, for example. So when I start to see pediatric feeding clients, I will give them an informal screener to see, hey, do we have some retained primitive reflexes? Because if we do, then our body is not only working harder to do what it's supposed to be doing, but it's also making it hard for the child to refine The fine motor movements of the mouth, the tongue, the jaw, the lips. So I get clients for feeding, I always consult OT. And whenever OT gets clients for feeding, a lot of the time they also talk to me as well because we want to work together to see, okay, what are the priorities? How are we going to scaffold the support here? So for example, I will get a client who has a restricted food repertoire. I will informally screen, hey, we still have our Moro reflex, we still have our palmar grasp and our rooting. So then they'll go to OT, they'll see OT for a little bit, they may come back to me, or we may have an intensive and work together to really just push progress along. So going back to integration of all of us working together, that's basically what I do every single day. We all, basically everyone within our practice shares clients for the most part. Hey, they need some airway work. Hey, they need some OT. Hey, they need PT or speech. And it's been really cool to see progress happen quicker when we all work together. It's been cool.

Yeah. And I think it's interesting, I was talking to a friend because sometimes kids will make progress in one area and they completely pause or even backtrack in another area. We'll see major gains with walking and then the child falls a few weeks back on their feeding, the skills that they were gaining, their oral motor skills. And it's not that they've lost them, it's usually just that all that energy is going to that one big milestone that they're developing and really perfecting. I don't say perfecting, but gaining and So anyways, we were having this whole conversation about it, but you wouldn't— would never know these things if you're not talking to the other therapists. And I've had OT in my private practice. I've also had them— and right now we don't have OT in my practice, and it's still so critical whether they're in your practice or they're an outside team, right, to have these conversations. And it was one of my most favorite things. I was working in this one preschool, even though we had OT in my practice, they had an OT there before my speech and feeding team entered the picture. And so they kept that OT practice, and we would just collaborate so beautifully on The different kiddos that we were seeing passing each other in the hallway and just saying, hey, this is what we were working on this week. What are you using? What am I— and that's where I would find out they were making these major strides while I'm like, okay, feeding was a little tough this week. That makes sense because we're making big motor gains in other arenas while feeding took a little bit of a backseat. And we've seen that with language growth. We've seen that with fluency, even at times where kids have become a little disfluent while they're having these massive language growth spurts. And then a couple weeks later it goes away. You're like, Huh, that was interesting. So all these little things that you don't always have really a good lens into without talking to the other providers. But even with other providers like ENT or an allergist or the ortho or the dentist or whoever might be on that child's team, knowing one, why you refer and what you're— why you're concerned and why you're sending them there. And then getting that follow-up conversation from that provider to understand, okay, here's what I saw. Thank you for telling me why you were sending them. It's like, Hallie, I send people to the ENT all the time and they come back so frustrated because ENT did a quick look-see and sent them back and said everything's fine. And I'm like, well, did you get— did you try to get on the phone with them? If you couldn't get on the phone with them, did you send them a 3-bullet-point summary directly as to why you're referring this kid so they understand what your concern is and why you're making this referral? I'm like, because without that information, they don't know why the kid's sitting there. They're going based on what the parent's telling them, which may be helpful. Maybe the parent is really cued in.

Yeah.

But also let's connect as providers. I know it takes time and I know it's a lot of work and I know we don't get paid for it necessarily, but also in order to get the kid towards graduation but not keep these kids on our caseload forever, if we're going to make the effort to refer, let's also make the effort to collaborate so we can integrate the findings and really treatment.

Yes. And what's been really helpful with collaborating is also being able to explain to parents why we're seeing what we're seeing when they come to me after OT. I have some kids who receive OT who have trouble crossing at midline or using both sides of their body and establishing a strong brain-body connection. And then they'll come to me because maybe they'll have some open-mouth breathing and some limited lingual range of motion. And I'll explain to parents that gross motor skills are the foundation of development. We need The strong— the mobility of the lip starts at stability of the hips. We've talked about this, and I'll be— I'll explain to parents the fine motor of the tongue being able to cross that midline, being able to lateralize and masticate. That all happens when we have a strong foundation of gross motor skills. The fact that you're receiving OT because we're having difficulty with these gross motor movements makes sense to me that we're having trouble with the fine motor movements. Being able to now explain to parents, hey, this is what we're seeing and this is why we're seeing it, and this is how we're going to work together to help your child improve the brain-body connection, improve stability and strengthen the body, and also improve their oral motor skills and expand their food repertoire.

Amazing. And I think that leads into even just having a conversation about the jaw, right? Stability and strength and jaw grading. The jaw's a thing. I feel like it gets ignored a lot of times, at least in the SLP side of things.

Yep.

Which is wild to me. Or you'll hear people say, oh, we don't really have to grade our jaw that much for chewing, or we don't have to grade it that much for certain speech sounds. Well, okay, maybe that's true, but poor jaw grading is a thing. So is that something you're also like looking at? I'm guessing yes, because hello, CPFT.

So with the jaw, I remember being so scared of it. Because I didn't know what I was looking for, like how to assess the jaw. But when I have coworkers or Regina who says, oh, he had a wild jaw, and I'm thinking, what do you mean? This chewing pattern, but what makes it wild? So I had a really hard time with understanding what am I supposed to be looking for outside of chewing patterns? And that is when the MyoTools from TalkTools really helped. The early feeding skill text book I have and the OPT textbook, the Oral Placement Therapy, really helped with assessing jaw grading and jaw stability because we need both for feeding and speech. And it really helped yesterday. I was working with a client who just needs help with R. He needs help with the R phoneme because it always gets— turns into a vowel, always. And I realized, ding, ding, ding, ding, he has difficulty with jaw grading. He's opening his jaw too much and it becomes this ah versus er.

Ah.

And I explained to Dad, watch me, watch me go from uh to er, er, er. Do you see my jaw moving? And he goes, yeah, but what's the problem? And being able to explain, we need to be able to grade our jaw, be able to control the opening and the closing for both speech and feeding in order to hear that clear R. And once I gave him bite blocks and once I cued him to keep his jaw a little bit more closed, All of a sudden we heard that R come in. And that's something that's really been lacking from my practice for a long time because I didn't know, I just didn't know what to look for. It was never explained in graduate school or post-grad school. I had to complete CPFT, Feed the Peds, MyoTools. I had to do these things in order to know what exactly I'm looking for and why it's important. Because people may just say, yeah, you have a jaw, it's strong, can't really be changed. So let's look at the tongue. And you're right, I feel like the jaw is often passed because we go right to the tongue, we go right to the lips, but we don't look at the jaw. And the jaw, when it comes to feeding and speech, is the foundation. We need jaw grading, we need jaw stability and jaw symmetry. In order to start working on the more fine motor movements of the tongue and the lips and the dissociation of those 3.

Yes, I love it. You're like preaching to the choir. I feel like I— and it's so interesting because it's so funny, like when I teach Feed the Peeds, right, everyone's like— or even the free 3-day training, people are like, but what is— what does chewing look like, right? So they get very stuck. Like you said, you were very focused on the chew patterns, right? And I was like, wow, okay, no one's ever taught you this. Let me just give you guys a really easy example and demonstrate with a puppet just to show you the general patterns, right? Obviously that looks on it, it looks different on an actual kid's face. We're updating Feed the Peeds right now. We're putting more of that stuff in because I'm like, I need everyone to see what this looks— everyone's like, what does this look like in practice? We're like, we got you. But now as you're talking, I'm like, huh, maybe CPFT, even though it's a pediatric feeding course, maybe we need a jaw grading course.

Yeah.

Just the jaw, because I've always— I'm sitting here going, I've always preached that the jaw is a foundation and the jaw has to be stable and we need to be able to have different heights. And we've given examples. I'm like, but if it's not— if you came out and you were were still like, hmm, dog training is not something I feel really confident about or really know much about. I'm going, okay, we could put this in here. It's not a speech course, so we're not going to go too deep into the speech stuff. But with our new Integrated Therapist Program, launched basically the new program with a tongue tie and speech training that I created. And that's because I was like, this is also interconnected whether you're a speech therapist or not. I just feel like everyone needs to listen to this information and hear it and understand the impact on the tongue and What's required of the tongue to produce these sounds with the surrounding oral structures. So anyways, I'm just like over here going, yes! I just, I love when integration happens in our brains because even us integrating the information that we're learning so we can apply it to the patients, it's so good.

It's so cool. Yeah, back to how important gross motor is. Now when I evaluate my kids, I will just see How they prefer to play position-wise. Can they sit at a table? Do they need supports? Do they prefer to lay down while they play? How does it look when they run? How does it look when they walk? I start to look at the whole little body and not just what's happening right here. And I think that I can easily— I used to get easily stuck with what's happening right here specifically, maybe even right here, and not looking at what's happening. I was evaluating a child a few weeks ago And I noticed that he just wanted to be on his belly playing, and he's about 3. And I asked him to sit up and he said, no, my tummy gets too tired. And just thinking, so we really need to work on our core. Not to mention he has the mouth open and then multiple bibs throughout the day. Of course, all of these things go hand in hand.

Yeah. What we see on the hips, we see on the lips and vice versa. 100%.

Yep.

It's always a good reminder of like how interconnected we are and needing that core stability and the strength to really hold us up and even make progress up here. Absolutely.

Oh my gosh.

Such good stuff. Okay. I have a couple questions for you.

Ask me.

So for a CPFT graduate who is wondering whether MYO might be the next step for them, what would you tell them?

Because like we were talking about, it's only one side of the coin, right? So if you complete CPFT and you love feeding and that's your thing, that is wonderful. I would say keep going, keep going. Include CPFT as something that's part of your toolbox and be proud of it, right? Be proud of it, but don't stop there because there's a whole other door that leads to a whole other world of knowledge that's really important with this feeding group. When you see kids who come in with either picky eating, disordered feeding, It is very likely that you might see an open-mouth posture. You might hear snoring. You might see enlarged tonsils. You might see poor tongue-jaw-lip dissociation. You may start to see these things that do impact feeding. And if you address just the feeding, you may make some progress and you may do good for this child. But at some point, you may start to plateau and you're going to ask yourself, well, why I'm doing all of the things I learned about. Why am I not making progress? And it might be because we're missing a whole other side. So the short answer is yes. You've finished CPFT and you want to extend, you want to expand your skills. I would say the next step is MYO. And then get yourself a good mentor. Get someone who is open to you observing their sessions, Picking their brain about what they're doing, why they're doing it, asking them what courses they've taken, and just— and sharing knowledge. As soon as, as you learn something, share it, because I think that this information should really be shared far and wide. And that's a huge reason why I was so excited to be back on the podcast, because I've learned so much that I think A lot of SLPs, a lot of clinicians don't know and don't know the importance of knowing this knowledge about both feeding and MYO. So the answer is yes, definitely pursue MYO.

I love it. Okay, another question. So you're also an autism specialist. How does the neurodiversity-affirming, child-led approach, like, how does, does that change how you do your MYO work?

Such a good question. It does. It really does. And again, this might be a hot take. It might be. So incoming hot take.

I love it.

I learned that with myo, it is optimal when a child is sitting in a chair with support on the feet and at the hips and they're well supported. And a lot of my autistic friends love vestibular input, love movement, love to be running around. So when I provide myofunctional therapy, For children who are a little older, who are on the autism spectrum, I tend to modify it. So it might not be textbook Mayo where we are completing this hierarchy and going up, up until we've achieved the hierarchy with these repetitions. What I'd like to see is that the child is motivated, that they feel safe, that there's a connection with me, and that they want to follow my lead. That is the foundation. So sometimes My Mayo can be done on a swing. It could be sitting on a swing, and we are going to chew on our chewy tubes for the chewy tube hierarchy while we are doing a puzzle. And then after we complete the puzzle, we get to swing a little bit back and forth. Or maybe there's no puzzle, and we just have a little bit of movement while we are practicing lip puckering and getting Lips closed. So yes, the answer is yes, it's going to look different. I would still consider it Mayo, but I think with the autism background, we need to see where they are coming from and what they're able to do. Because just because there's an autism diagnosis, just because we need supports, it doesn't mean that we have to wait. And it doesn't mean we have to do things by the books in order to see progress. It just means that we are seeing where the child's coming from, meeting them where they are, And giving them the support they need to be led a little bit. Because Mayo, there is a lot of clinician-led directives within Mayo, right? So what I try to do is meet the child where they are, get them motivated, see what I can complete and how I can get them to improve whatever it is, the lip closure, the tongue retraction. I just do it with a little bit I love that.

And I think it's really functional because at the end of the day, if these are kids who are going to be constantly on the move anyways, they need these skills in those situations, right? So I just, I love the modification. Now I'm also someone who learned, which I would argue was a little textbooky, like step 1, step 2, step 3. And I very quickly came to learn you don't have to do myo that way. Not everybody needs every exercise. Not everybody needs the same approach. We need to individualize it.

That's right.

And that's why I always say, I've always said this with feeding, but it goes for myo too. As therapists, there's a dance between art and science, and yes, we have to be thinking on our toes. How can I address the goal at hand with the child in front of me and meet their needs, right?

Yes.

So I love that, and I honestly, I know we could call it modified, but at the end of the day, I'm like, if you're working toward that same end goal and you're achieving that with that kid, I almost don't care how you got there. Even though it's easier when they have tush in seat and they're looking straight at us, totally way easier.

Yes.

Sometimes, not always, but some, most of the time. So I do think it's a really, it's cool. Thank you for speaking to that because I don't want people to see a child and a diagnosis and automatically go, no, Mayo's not for them. I mean, I have done Mayo, or like you said, modified it with children at various cognition levels over the age of 4 cognitively is my minimum that I'll start at. But they could be chronologically 13 years old and they're functioning at the level of a 5-year-old.

Mm-hmm.

We'll work towards our goals. I like to have that minimum 4 years, and obviously it's going to vary child to child, but children with Down syndrome, children with all kinds of different diagnoses that we were still able to make beautiful progress. And I always talk about, I think you saw him in the course, but, and even in CPFT probably too, one of my most favorite kiddos who was like 2 or 3, we weren't doing myo yet, but I, we were prepping him for a lingual release and he was my best little tongue clicker. And every time he saw me walk into the room, he would just be like, And he didn't have a ton of speech at that time, like vocal output. He would just go like, Hallie, or hi. And like, I was the tongue click lady. And so—

You're the tongue click lady.

So sweet, because I was like, look at what you can do when you have fun with it, when you get down on their level, when you let them lead the way, and then they start imitating you, right? And so anyways, all that to say, the integration of feeding and myo and functional skills, it's just, it's so important not to just write A child given a diagnosis and really give the child a chance and see what you can modify. Yeah, because I'm with you, that whole wait-and-see approach. A lot of people are like, oh, we gotta wait till they're 4 or 5 to do Mayo. Sure, traditional Mayo programs, yes, cognitive age, but also we can adopt it and do it with younger kids because why make them wait, right?

And, and that says something. And then going and then commenting on what you're saying, how when I see autistic twins In South Philly, one of them loves to be on the trampoline, and mom said, "I really want one of his goals to be that he'll be able to blow out his birthday candles because he doesn't know how to blow. His lips are always open; they're weak. He has difficulty with that range of motion—the retracting, protruding. So we will learn the to blow bubbles via OPT, but on the trampoline. So he will be jumping up and down, and I'll put the wand a little bit at an incline. So when he jumps up and he can. jump and then blow. And that's, again, it's modified. It's not necessarily traditional textbook Mayo, but we're working on lip rounding. We're starting to get blowing, and he's doing it in a way where he feels safe and regulated, and I don't see anything wrong with that.

I love it. I think that's awesome.

Yeah. And then what we were going to say is, yes, Mayo, you were talking about cognitive levels around 4 or 5, And before that, what I learned is that some myo clinicians will call less than 4 years old baby myo. And I have learned primarily through you is that before that, it's just feeding therapy. It's just pediatric feeding therapy. I learned it from you. I've learned it from Robin Merkel-Walsh through the MyoTools course I took where she had this exercise where she would would take out her Sensi and then model an oral motor exercise and then ask us, was that myo or was that pediatric feeding therapy? And the first time I took the course, I got it all wrong, every single question wrong, because everything looked like it was the other. Everything looks the same. But then after I've studied, I've realized myofunctional therapy, we are giving them the support to do something themselves eventually. With feeding therapy, I'm giving you all everything that I give you so that way you're doing what I want you to do. If I want to target tongue lateralization and we're not, and we're not moving our tongue, I'm going to stroke your tongue with an oral motor piece to giving you that stimulation for you to lateralize that tongue. That would be feeding therapy that I would be providing. If I give you a lollipop and I put it in your cheek and I say, try to lick it, and I give you a bite block. So we have jaw stability, and I have a target right here, and I want you to just move your tongue. And I'm not touching, I'm just saying, here's the target, move your tongue. That would be myo. And I think—

Like the passive versus the active, right?

Yeah. Yes, it's passive versus active. That's another thing I've learned when working with my clients, whether they are autistic, whether they're 4 years old or 3 years old. I'm just constantly learning how to Because we have the same goals. Like, a lot of these kids may have similar goals of, we want to establish habitual nasal breathing, we want to have strong lips, we can keep them closed at rest and eliminate tongue thrusting. But they might need different levels of support, they may have different levels of cognition. And that is something that we can use to help us determine, are we providing feeding therapy? Are we providing Yeah.

And that's why I like to call it under the age of 4 cognitively, I'm always like, it's like feeding with a twist of TOTS and MYO because we don't know what spices we're throwing into the mix here.

It's a hybrid.

It's a little hybrid. And really at the end of the day, the way that we approach the MYO skills, which I say MYO skills, it's really airway. How are we breathing? Where's our tongue at rest? Correct oral rest posture. How are we chewing? Where is our tongue? All the things that we work on in MYO, it all under the scope of a pediatric feeding therapist and is typically done in a passive way like you've been explaining. And so I'm like, it's hit so cut and dry. I know for so many people it is not, but that's also why I just keep preaching that. And I know Robin and I are like, we work together in trying to get this message really, really get it home. But anyways, yeah, it's— this has been fantastic. All right, last question, then we'll wrap up. What is one thing that maybe you would tell your pre-CPFT self?

Don't view Mayo as a beast. It's okay. It's like a little pet instead. Don't be scared of Mayo. Mayo's not going away. So if you're pre-CPFT, what I would say is follow that passion. Love feeding as hard as you can. Do not shut out MYO because it's just around the corner.

I love it. As we're sitting here, I'm like, I feel like we need the jaw grading, but I think maybe also we need a 2-hour MYO course in there. 'Cause it's like, I have the module in Feed the Peeds. I'm like, maybe we just need to put a module into, or not module, but actual course into CPFT too, just to really drive this home. And then people can go on to do deeper education outside of CPFT, but I'm like, I don't want anybody leaving CPFT not knowing that this is important information that you should be using with your patients, even your pediatric feeding kiddos. Anyway, so this was so good. Thank you so much, Sami.

This was awesome. Thank you.

Where can people find you? I know you said you're in Philly, you're working with Regina, but if they wanted to book directly with you, how can they find you?

Yeah, absolutely. I work for Be Well Tots. It's a holistic pediatric therapy private practice here in Philadelphia. So you can follow us or find us at Be Well Taught. My name is Sami Hernandez, and it has been a pleasure. An absolute pleasure. Thank you.

Thank you again for rejoining me on the podcast. Quick disclaimer: all information, content, and material of this podcast are the opinions of the speakers and serves as informational purposes only, and not intended to serve as a substitute for the consultation, diagnosis, and/or medical Thanks for listening to this podcast. If you found value in this episode and want to hear more of these myotats, airway, and feeding-related episodes, be sure to leave a review on Apple Podcasts and share this episode on your social media platforms. You can access free resources and all I offer at halliebulkin.com or pop over to @holliebulkin on Instagram to get all the latest updates.