Making Sense Ep 6
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[00:01:04] Madi Metcalf: Welcome everyone to Making Sense of Selective Eating, Oral Motor-Sensory Development and Feeding Skills. My name is Madi Metcalf and I'll be your host for this podcast. This episode will feature Diane Bahr, MS, CCC-SLP, CIMI. Today's course is one hour with no breaks. This course will be offered for 0.
[00:01:24] If you're part of the ASHA registry and want your CEUs to be reported, you must have your ASHA number and address in your speechtherapypd. com profile. Please allow one to two months from the completion date for your CEU to be reflected on your ASHA transcript. Now, without further delay, I'd love to welcome Diane Bahr.
[00:01:41] She'll be our guest for oral motor sensory development and feeding skills. Diane Bahr is a certified speech language pathologist and infant massage instructor. She is a visionary with a mission. For over 40 years, she has treated children and adults with feeding, motor speech, and mouth function problems.
[00:01:57] While she's a speech language pathologist by training, she has also honed in her skills as a feeding therapist, published author, international speaker, university instructor, and business owner. Additionally, she writes articles appearing in a variety of publications and is interviewed frequently on radio and podcasts.
[00:02:15] and for magazines. Diane is the author of the textbook, Oral Motor Assessment and Treatment, Ages and Stages, and two parent professional books, Feed Your Baby and Toddler Right, Early Eating and Drinking Skills, Encourage the Best Development, and Nobody Ever Told Me or My Mother That, Everything from Bartles and Breathing to Healthy Speech Development.
[00:02:34] Hello, Diane. Hi, how are you, Maddie? I'm doing wonderful. How are you doing today? 
[00:02:41] Diane Bahr: I'm fine and I feel so honored to be here. I really, I've done one of these before. For speech therapy PD before, and I'm really excited to be doing it again. 
[00:02:52] Madi Metcalf: Well, I am so honored to have you on. I have learned so much from your articles and books that you've put out.
[00:02:59] And so having you be a part of this is just really exciting for me. So thank you. 
[00:03:04] Diane Bahr: You're welcome. 
[00:03:05] Madi Metcalf: It's my pleasure. So, let's jump in to the good stuff. Okay. How do oral sensory motor skills relate to feeding development? 
[00:03:16] Diane Bahr: Okay, well, I thought we'd start out with some basics of sensory motor learning.
[00:03:22] Madi Metcalf: Perfect. 
[00:03:22] Diane Bahr: So, sensory motor learning, no matter what age, beginning of birth Babies actually aren't given enough credit for what they can do at birth, and we on our website have literature based checklists beginning at birth to 12 months in English, Italian, and they will soon be in Spanish. So for those people looking for those guidelines that are based on the literature, they're there.
[00:03:48] So, since, as I said before, sensory motor learning requires attention, focus, and concentration. And we know even babies from birth, they are making eye contact. They can imitate some mouth movements, those kinds of things. And this is because we have mirror neurons in our frontal lobe of the brain. And so you can read a lot about that.
[00:04:21] And, you know, just go and googling it or I like if you're a therapist, which many of you are, just go and Google scholar and look this up and I have references too, and I'll give you contact information so you can contact me if you want. Everybody seems to know that I'm willing to answer questions. Right now I'm working on two big, big projects.
[00:04:47] So I am not actively treating, but I love to treat and can't wait to get back to it. And so also back to sensory motor learning, it occurs in steps and stages. So we really have to look at there's a rapid acquisition stage, and this is true for everybody. Okay, there, whatever age, because my youngest have been newborns that I've worked with, and my oldest have been age 99 and then there's a slower.
[00:05:25] Consolidation stage when we're learning and then there we do things step by step and we call that integral stimulation. I have to say that slow so I can say all the syllables. And then we learn generalization through variations on a theme. Now, Suzanne Evans Morris has been my mentor since the 1980s, and she still is.
[00:05:51] And so, variations on a theme means, means that we do things similarly, but in different ways. So, a lot of times our children, especially those who become picky eaters, will get stuck on a particular cup, a particular I mean, they'll even get very specific about the foods they'll eat, you know, when they see the packaging and all of that kind of thing, or colors, and we're going to talk about the problems with picky eating, and then we're going to go through what is typical.
[00:06:25] So, my goal is. to help parents and therapists help parents to keep children on track from birth. But when they go off track, that doesn't mean that we can't get them back on track. And you have seen a 17 year old I worked with, with Down syndrome, who, and that's in the course, the speech therapy PD course that I teach, you have seen that he Wasn't successful in any feeding program until we really paid attention to some of these things we're going to talk about today.
[00:07:03] So, what is the importance of good mouth development? I'm just going to read this to you. It's in both of my books, but good mouth development is extremely important for, as we know, health and well being. It's not only the route to good nutrition, It's the route to information and we know babies explore their hands, they explore objects, they're teething, we're going to talk about oral awareness and discrimination and how that develops, and a lot of our kids who are picky eaters have kind of skipped over.
[00:07:42] This oral awareness and discrimination state and birth to two is the critical learning period. For the development of math skills. So by the time a child is two years old they should be pretty much eating and drinking like we are Suzanne Morris did some of the best work in this area, and there's work throughout the world.
[00:08:05] In fact, in the new course I'm writing, I found a recent survey of parents from different countries, and what they found is that children actually can, excuse me, stay, let me clear this voice here, children can actually stay on track according to what Suzanne found in her studies. From birth to 2 to 3, and that's where we get a lot of our information, but there's many, many articles out there.
[00:08:33] The new course I'm working on has 11 pages of A. P. A. reference. Oh, my goodness. 
[00:08:40] Madi Metcalf: That's amazing. 
[00:08:42] Diane Bahr: Because I'm trying to give everybody the full view of what we need to to either go to, because you don't need to, be treating everything in the world. You need to identify what it is you need to treat and then go there.
[00:08:59] And then also working with the family, when you read my sample recommendations, which I'm happy to give to people. The first thing you'll see on it is the parents and family needs to be working together with the child so that even I even have a parents, a Using Beckman tri choose and are an arc why shoes with their babies so that the baby because of the mirror neurons.
[00:09:27] Oh, you know, by three months, a child can be doing some of those kinds of things, of course, with supervision and I've had a lot of success with siblings, not all siblings, necessarily. That, but some siblings are perfect to be doing this at home. And my daughter has three children, and she's an SLP. And so, she keeps her oral discrimination and jaw activity at You know, things in a drawer.
[00:09:58] The kids can get to that safe and in her kitchen. And she's done this since they were small. 
[00:10:06] Madi Metcalf: So let me ask the question really quick. What are, so whenever you talked about using like the Beckman tri tube and the arc wide shoes, what is your purpose in doing that? 
[00:10:18] Diane Bahr: Okay. 
[00:10:19] Madi Metcalf: Littles. 
[00:10:19] Diane Bahr: Right. So, by about three months, a child, well, let's, we can start from birth.
[00:10:26] We're going to talk a little about the reflexes, but the phasic bite response is there from birth. And the child you know, if you're in the mouth with your gloved finger and the parent is in the baby's mouth, babies actually love this. I listened to Aaron Roth. At the feeding conference here in Las Vegas last year, the talk Tolstead, and, you know, she said that oral defending this oral defensiveness is learned and I do believe that so that's something that happens because often we will take no.
[00:11:04] For an answer and also we have children using pacifiers, for example, which only elicits the sucking response, whereas the basic bite response. And I have a free course where you can see Kate and she's a 1 month old. And she was having trouble breastfeeding. She was typically born and I couldn't get tongue cupping with my finger down her tongue.
[00:11:33] She was only humping her tongue and she, her mouth just didn't seem to have a lot of organization. And I went back to where the molars will be. And that is where the best activity happens because they, the babies love to bite. Bite, bite, bite, bite on the fleshy part of your finger, and then the other side and I have this in the free e course, so anybody can ask me for that free e course and, and that'll help you know.
[00:12:05] So, right away, we're not going to give them a mouth toy, like a why chew or a try chew, which are two of the ones I really like, because they're small enough to get back here at where the molars will be, and the molar area is crucial. It works the back and base of tongue. It works the soft palate. It works.
[00:12:28] Everything connected to the hyoid bone, so all of the floor muscles of the tongue connect to the, you know, the anterior belly of the digastric, the mylohyoid. The reason they have hyoid, because the hyoid and then the back and base of the tongue also connects to the soft palate. There's a muscle, the pal of glasses and the ty glasses.
[00:12:55] Also connects the tongue to the styloid process of the temporal bone. So, when you're doing phasic bite response, and babies like to bite, bite, bite all along the gum surfaces, and particularly at the molar area, when you're doing those activities, and at three months I start them with those two mouth items, because they're the right size for the babies.
[00:13:21] Chewing and so with the try to what's nice is the baby can hold it like a triangle and I have the parents use the smaller ones with the babies, the smaller parts of the triangle and the why to the baby and parent can the parent can help the baby to hold it like this. And then when you're at the. Or I don't think you'll be at the IOM, but you, you are one of our IAOM volunteers, but I asked ARC to include the Y Chew in, in what they're sending because the Y Chew is similar to the Tri Chew and is a right size, and you can hold it by the handle and move it back, back, back, and the parent can do it too.
[00:14:09] And by the way, parents. And therapists, I find I had a jaw slide and I've had my palate expanded. And the whole time I was getting all this work done over two and a half years. And of course, this is my like my 44th year in treatment. I do the work along with my clients, no matter what I'm using. So, and, and I eat along with my clients and I have the family spring food if I'm working in my office, or when I do a family home visit, we sit there and we eat together and we learn appropriate ways of eating based on age.
[00:14:46] And so, and I'm also somebody who, when a child. Rejects whatever it is that we're doing. I don't stop on a rejection. I do listen to it as communication, but then I go back to a place where. With what they enjoyed and we always stop in a place with what they like and enjoy and especially when they don't see with eating other people eating with them, you know, and the spoon is coming at them like a missile.
[00:15:23] So that's a big part of the process for me is doing the work that family doing the work and those kinds of things. And it's simple. Simon Wong is in Australia. I've taught in Australia in three cities, and you know, he and Sagar Khan, who wrote The Jaw Book they talk about how so many of these things can be done with everyday activities, and that's what I focus on.
[00:15:51] I don't want to stress a family out, and when I give activities, I usually only give one or two that seems to fit in. 
[00:15:58] Madi Metcalf: Oh, I like doing that like lower frequent or like fewer exercises. And then that's something that I found that my, I've always gotten really good feedback is if I tell them like, Oh, while you're doing this and like, while you're giving him a bath, like, that's a great time that you could, you know, you already have clean hands.
[00:16:14] You can do some phasic biting and that sort of thing. If I'm working with littles, but finding ways that they can build those activities into their daily routines that they're already doing. 
[00:16:23] Diane Bahr: Right. And so like our youngest. A grandchild had a very rough start because of medical complications, and so his dad would sit with him in his lap, and they put some kind of short video on, and I don't recommend videos as reinforcement, and kids get stuck on that.
[00:16:45] I don't, I recommend use of appropriate things, but his dad would sit with him, and of course both parents used They use the yellow chewy tubes, the parents, but would sit with him and hold him as they're just kind of looking at a short video. And because that child that visual was very common for that child.
[00:17:10] I usually don't recommend videos, but as my grandchildren got older, when they watch videos, that's the other thing. And my daughter only allows. Certain videos for a certain period of time. She doesn't do much screen time with her children, but also when they're reading. So what we did with all of her kids.
[00:17:30] Was they read books every night and they could have their mouth item with them while they were reading and looking at books and really books can be started from birth because babies understand intonation and they understand more language than we think they do early on. So, do you want to talk about picky eating or you have another question?
[00:17:58] Madi Metcalf: Yeah let's dive into picky eating and how that skill can relate to how we want to eat. 
[00:18:04] Diane Bahr: Okay. So, with picky eating, I have this slide here that I usually use and all of my, well, most we have to consider the food tastes and textures. Whether they were introduced on time and I'm going to give you some of those times and they're in my book and as we know now with a recent survey of parents that children really can be kept on schedule and on time, but we don't want to pressure parents or therapists because everybody kind of has their own journey.
[00:18:41] And they're going to do things as they're ready. The problem I see with picky eating is that we've skipped over some of the typical things and parents and therapists often don't know what those typical things are. So, you know, for a therapist who don't have children, you have to have some kind of a guide.
[00:19:03] I was lucky when I became a therapist. I had already had my daughter, I had breastfed her, you know, we, at that time in the 70s, we did our best to keep eating and drinking on schedule, so, and we knew about Open Cup and so, and she didn't bottle feed, I'm not against bottle feeding, they're just different, so we can talk about that if we get to it, because I know you only have an hour and you're going to keep the time.
[00:19:35] Okay, so, and then sensory preferences. We have to look at taste, texture, temperature, smell, color, shape. And we have to look at what the preferences are. So with Ian, for example, when I met him at 16, he had Let's just talk about his health problems. I'm going to talk about nose breathing a little bit, but he couldn't breathe through his nose, his mouth was open.
[00:20:05] His tongue was hanging out. He had cracks in his tongue from air, you know, being on his tongue. He was, didn't have a tube. So he was living off of vanilla pudding, baby food oatmeal and water.. And he tried, they tried other feeding programs, but he really needed one that was personalized to him. 
[00:20:30] So what we found was with taste, if you look at baby food, oatmeal, and vanilla pudding, what's a commonality? It's sweet and sweet and salty. are sensed pretty much near the front of the tongue. At least that's just a generalization.
[00:20:51] We know more specifics about taste these days, and there's some new research if somebody wants to go look at that taste information. So, of course he had a tongue thrust swallow, so he didn't have the motor ability. And in his body because he had Down syndrome he had low muscle tone. And so we have to look at the body related to the mouth.
[00:21:17] And you really need to have lateral diagonal and rotary movement in the body in order to get those fine motor skills in the mouth. 
[00:21:28] Madi Metcalf: If you see a patient that is having difficulty with those movements and their body, would that be a point that you would refer out to like PT or OT for support in that area?
[00:21:39] Diane Bahr: I have been lucky enough to work on full teams. So at the Maryland school for the blind, we had about 40 therapists. We had educators, we had doctors from Johns Hopkins that came into our campus because it was so beautiful. We had a medical center. We co treated with OT and PT. We had a heated pool.
[00:22:02] That we could treat in along with the PT to get those movements going. 
[00:22:08] We had wonderful gyms and OT and PT were right next to each other. When I worked on the traumatic brain injury unit at Maryland General Bryn Mawr Rehab, We had the same thing. We were a new clinic. We had all the therapists we co-treated in each other's spaces.
[00:22:26] We were a transdisciplinary team, so because we were rehab and I was on the brain injury unit, but I also worked on the stroke unit at weekly, we met together and decided what were our transdisciplinary goals. So we, and we had family style eating areas in both situations. Both so we had small dining rooms for the younger children that weren't overwhelming at, at the school for the blind.
[00:22:55] And then we had a separate one family style eating area in on the brain injury unit and one on the stroke unit. And then we were there working with them. Of course, we worked with them coming out of coma or whatever. And got their skills up to where they could go to the table and do a lot of this stuff. We didn't just sit at the table 
[00:23:19] Madi Metcalf: That is awesome 
[00:23:20] Diane Bahr: and postural control. When I was teaching for the brain, the Breathe Institute, TBI we looked at. A lot of typical people who had oral facial, my functional disorders, and I can specifically remember this man who was about 50 years old and in his body. He had, he didn't have when he walked lateral diagonal rotational movement in his body and then he couldn't pass an oral mechanism exam, which requires all of that.
[00:23:56] And so we had to use. Like bite blocks, a stabilized his draw to get him to be able to do those movements. And so I'll, I'll have that in my new course. It was in my io, IAOM plus I taught in 2022, and I'm happy to share that handout with anyone because if you aren't eating and drinking properly, if you can't pass a simple oral mechanism exam.
[00:24:24] And I also had the luxury of. Editing for Dr. Christiane Gimeno of Stanford. And so in his last article, he talks about the fact that a child by the age of three should be able to pass a simple oral mechanism exam. And when I went to school in the 70s, we were, and we were just getting into language. I was taught, Everybody that crosses your doorstep, no matter what the reason, you are going to do an oral mechanism exam.
[00:24:57] And then there was I think it was the SELF, which was a language test that had just come out at the time. And we did a Simon Says activity with them, where we could see what was going on in their bodies. And I was at this elementary school where everybody thought this kid was just an awkward kid.
[00:25:19] When we did Simon Says I found that he had some extraneous movement and he actually has cerebral palsy. And nobody at Miles. But nobody had really identified it until they looked at what was happening with his body and hands and mouth also work together. So that's why babies, you know, use the items we talked about.
[00:25:44] The other thing is looking at health issues, reflux, other gastrointestinal, gastrointestinal problems, nasal sinus, other medical problems. So, and. completely occluded sinuses. So he had no choice but to breathe through his mouth. So the first thing his family did was take him to a good auntie and get that cleared up.
[00:26:12] And that's why I had palatal expansion because I've had, and you can hear it now in my morning voice, my post nasal drip. I've had, I've had sinus problems all my life, but just having a broader palate opened up my airway because the palet is the floor of the nasal area. Allergies. I mean, I was the only kid I knew growing up that had allergies. Now, everybody seems to have some kind of allergies, whether it's food allergy, or whatever. And then behavioral concerns. The reason Ian couldn't make it. And other feeding programs is that hit behavior is communication and so people were so intent on getting him to eat.
[00:26:58] And I'm not this is no judgment guys because I know we've all been through this. I started treating in 1980. And so, I've been, I'm still working on this, I'm still learning, and so I've been through all of this, and I know how frustr how frustrating those behavioral issues can be, and we have to look at them as communication, and then, we, for Ian, we had a wonderful occupational therapist, who could look at his sensory, who could look at his motor, and who could also help to change those behavioral Thing into age appropriate things for a 16, 17 year old who we were working with at the time.
[00:27:45] So with the 50 year old guy who had none of that movement, his body, he was chewing, chewing everything at one premolar area, like five times and swallowing. Oh my goodness. We had to help him get an ergonomic chair because he had postural issues. And then we had to help him know that you know, what's appropriate eating from age two up because he obviously hadn't learned that and we can go over that.
[00:28:16] I have a slide on that. We can talk about, but back to sensory preferences when I look at them. So let's go back to Ian. He only liked vanilla pudding and baby food or not regular oatmeal. So what color are they? They are both like a bland neutral brown color. Yeah. Yeah. Beige. Yeah. I have an article in an autism journal called something like the Beige Diet, and we see a lot of kids who like to eat beige foods.
[00:28:48] So, we're not going to rip those away from them. We're going to change those two foods. So what we found with the vanilla pudding, for example, was that he would eat it from the refrigerator. He would eat it room temperature. We could warm it up and he would like it. He also would eat different brands. Ian loved to grocery shop.
[00:29:15] That was one of his things that he got to do for doing good work. And we had him on a behavior. It was actually his psychologist that called me in. Because we had him on a token economy. And so he got tokens as, you know, for his work. And then when he was able to do, but, but we didn't disrupt the feeding process.
[00:29:40] We, we kept that going. We didn't like you have to do what we did do some things where he got a token, but that was what he didn't know how to chew. When I met him, so we had to teach him to chew and so he got tokens for doing different chewing activities and working his way up from being able to just bite on something to being able to chew.
[00:30:07] And Cheryl from Nosh Sidebiter is going to be one of the people at the IAOM convention and she has created. A device that you can use all the way from babies of seven months to adults. Who need to safely learn to chew and you can put food in there that's appropriate will appropriately fit all the way back to the molar area.
[00:30:35] And so with Ian, we would send him to the store to do that. We didn't go from vanilla pudding to tapioca. Too big of a change. Okay. We didn't go from vanilla pudding to vanilla yogurt. We played with the temperatures and the different products he picked up at the store that were vanilla. But then we went to He liked color, so he bought food coloring from the store, and he was able to change the color by one drop of a color he chose of his vanilla pudding.
[00:31:13] Let's get back to the oatmeal. We had him make cooking. And making the oatmeal because the school had a a kitchen and his home had a kitchen so safely. So we had, we experimented with changing the texture just slightly. So go ahead. 
[00:31:33] Madi Metcalf: So with the token, I have a question about the token reward system.
[00:31:37] Sure. So with that, were you like using the tokens for him doing. Chewing activities that he felt safe doing, but then you said you kind of kept it away from the eating. So weren't like take a bite of your warm pudding and then you get a token. It was more than that, right? Chewing exercise activities.
[00:31:52] Diane Bahr: Actually, I went to a home where it, you know, We sent Suzanne a video and this, this family, this poor family, they were just trying to reinforce every time the child did something. No, no. And the other thing he needed to learn was a pace of eating. So when I met him, he was eating from a tablespoon. And of course he needed to eat from a small marine spoon.
[00:32:21] And and he was shoveling it in. And so we paced him. So yes, with his, his speech therapist wasn't comfortable with the work. So his OT did the work. We got him on the yellow chewy tube. And of course, we only worked. And we got it toward the back molar and we got bilateral yellow chewy tubes, which is really the best exercise ever.
[00:32:51] And I still do them. That's why I don't have a jaw slide now. Because that usually means there's one side that's weaker than the other. And I now use the IOP in different ways. I've used it since 1992, but once I get somebody chewing in a graded manner, I can actually check jaw strength at the molar end.
[00:33:11] Yes. And it's twice the jaw strength at the molar areas with it's a K Pascal measure than it is at the pre molar areas. Like I said, the older guy was only, you know, munch munch five times people. Right? No wonder he had GI problems, you know, and so no, no, it's not. It's not a tit for tat. So we used to say, we probably don't say that anymore, but it's not one for one.
[00:33:45] So we, if he chewed 5 times, and we did, he, because he likes sweet, we did move him to Sarah Johnson's technique of using the hardened And I'm not a big fan of candy and stuff, but because he liked the sweet, that was one thing that we can move him to after the chewy tube that he enjoyed. And, and we already had him do those things.
[00:34:14] And I would use the NOSH sidewinder with them now, but we use foods and cheesecloth. So from the time I started at the School for the Blind, we did programs where we put foods in unbleached cheesecloth and moved it back to the molars safely. Cheesecloth is a triple thickness. And you can throw it away.
[00:34:38] And so, if we got five chews, then he could get a token, five chews, and then we want, always want three sets. We're always following PT. So we want three sets, but the tokens are things that. Are related to what he wants to do. So he also had a program where he was prepared with this thinking by a story.
[00:35:08] Of what we're going to do. So his his classroom teacher and his classroom assistant and his father, they created stories of to prepare his thinking about and it's short. I mean, I only have an hour with him and we have to get through a lot. And with him, I only saw him once a month, but the work has to be done daily.
[00:35:31] And and a lot of times parents are overwhelmed because we give them a million things to do daily now. I look at what's going to work for the parent and the child, one or two things daily, takes two to three weeks to develop a habit, sometimes longer if you read the habit literature, and then we are going to do that daily.
[00:35:53] And that's why Simon Wong, who attended my course you know, is really big. He's an orthodontist in Melbourne, and he is really big on doing things naturally. And I always taught about the different tools, because everybody wanted to know about what they are, and I know what they're used for. And so, if you look at my speech therapy, P.
[00:36:16] D. course, you'll see me teaching about the tools, just so, you know, but actually. When you look at my current sample recommendations, which I'm happy to share, I really use very few tools and I move into natural work of eating, drinking, feeding as ASAP. 
[00:36:38] Madi Metcalf: I love that like emphasis on like, yes, we can use that tool to help facilitate a skill, like a good chew or chewing at the molars or tongue lateralization or whatever it may be, but then always relating that directly back to the functional feeding skill.
[00:36:53] Diane Bahr: Yes, it's not the same. So chewing on a chewy tube is an up down, it should never be sliding. It should always be up down. I used to use the red, I will still use the red chewy tube to increase some strength if I need to. So just to give you an example. So, the IOP was developed for checking the tongue and Joanne Robbins did the greatest work ever in swallowing.
[00:37:24] And so there's there are norms for the mid tongue. But I actually check the tip of the tongue, both with the strength of the tip of the tongue that we use to initiate the swallow from the alveolar ridge. I also check it on T, D, and N. I'll use the, I'll check the mid tongue, which is where the IOP is mostly used.
[00:37:46] And there's a lot of weak mid tongue out there, and the only speech sound that really, well, there's two that are mid tongue, ee and yuh, and I'll often check those, but I'll check the actual lifting strength of the mid tongue. And then I don't go to the gag. The gag is on the back quarter of the tongue.
[00:38:07] It should be. By six months, a gag, a baby's gag, should be pretty much like your gag, my gag. It's only the back 30%. It's protective, so we don't swallow things whole. And so I'll go toward the back of the tongue and the back of the tongue actually for me is about 40. And then if you check my premolar area.
[00:38:32] It's about also at 40 K pascals. If you go to my molar area before I had my pre molars, but back in with my palatal expansion, my jaw area was about 80 K pascals. And once the pre molars were back in, it's now 100 on both sides. And if I notice my jaw sliding and therapist, you'll notice this, especially with kids with their sibilant sounds.
[00:39:00] So they're S, Z, S, H, those sounds so if you have them say, my sister Sally, or whatever, and you'll see, and watch the people on TV, you will see a lot of them when they're talking, they have jaw slides on their sibilant sounds. And that means, That they don't have equal jaw strength. Now, I'm not telling you to use the IOP that way.
[00:39:27] I talked to our heart about this, who is the daughter of Eric, the engineer who developed it and you know, she said, it's fine for you to do, because, you know, that somebody's jaw, somebody's not going to bite through it. In other words, right now, if you're using the IOP, just start using it. Exactly how they tell you, on the tongue, and they've changed the lip and cheek one.
[00:39:54] which has to do with inter interoral pressure. So we need good interoral pressure for a good swallow. And, and a lot of the clients we have don't have that good pressure. So it's another sensory motor skill that we need. And so we need to do a good feeding evaluation. And I still use the pre feeding skills checklist birth to two, and then we have the other checklist literature based On my website, and then we developed an assessment when we were doing research at Loyola, and my daughter and I have turned that into a clinical tool where you can just, you can just look at feeding.
[00:40:38] You can just look at whether they can pass an oral mechanism exam, but it has the full gamut of oral motor. It doesn't have sensory because I always work with an OT. My OT just. left here after 25 years. So, you know, I, I'm spoiled. I've always worked with a team and I, I do refer and things have changed since I was a young therapist.
[00:41:06] As a young therapist even in the school system, all 12 of our speech therapists met monthly. And so while we didn't have a full team I lived in a small area where we could work closely with the other people that were there. School for the Blind had it all and they were all on one campus.
[00:41:28] Maryland General Bryn Mawr had it all, we were all on one campus and we even had an apartment where we could take our adults and make sure that they could do all of the stuff that they needed to do. But do you want to talk about resolving picky eating? Yes, let's do it and then I can kind of guide you guys toward where typical is.
[00:41:53] Because typical is still typical, and it has to do both with not only typical sensory motor skills. It has also to do with the introduction of typical introduction of foods and, you know, like peanuts with allergies is one of the things that we learned a lot about. So, we now know that 1 reason people have allergies is that foods have been kept out of their diet.
[00:42:22] And so, and it's why we carefully introduced foods into diets. You know, like 1 food every 4 days and we look for rashes and whatever else. So we can look for that. I mean, this is a huge area. You're asking me about. 
[00:42:37] Madi Metcalf: I know it is such a big topic and I 1 thing that I love is like, yes, we're talking kind of about that.
[00:42:45] Feeding skill domain. So there's the four domains of PFD medical, nutritional psychosocial and feeding skill. And so we're really honed into that feeding skill in this talk. But what I've loved about this is that you just keep bringing up, yes, we're talking about feeding skill, but we can not consider these other areas.
[00:43:01] Even though this is like my domain, 
[00:43:04] Diane Bahr: The whole person, I couldn't get. I did learn NDT neurodevelopmental treatment for Lois Bly, and I use a lot of her work. And I've used it in the developmental checklist because she did a typical motor development. Book that I love. And I learned a lot from Pat Wenders.
[00:43:22] She, she was the PT who treated the kids with Down syndrome, and she had a private practice. She was at Kennedy, but then she had a private practice right off interstate 95 near me, where my private practice was, say, 95. So the kids would come even from out of state. They'd see her, they'd come see me, the parents.
[00:43:44] We had a family environment. I had a full apartment with a kitchen. So, you know, we could do whatever we needed to do. Not everybody. I say, I have lived an ideal therapist life. When you think about what I have had access to. Now, resolving picky eating here, a three day minimum food record. We had a very, we still are having a hard time, Las Vegas is really coming up medically, I moved here for the weather in the airport because I was teaching so much and I had allergies.
[00:44:23] So, and, and you can fly almost anywhere. from Las Vegas, even to Europe. One flight. So it's a good thing. But we need a three day minimum food record that includes snacks, you know, and we need to look at the person's behavior and family eating patterns. So if the family isn't eating and drinking, typically, then the child, whether they, you know, people will say kids with autism.
[00:44:55] I had people in my family with autism. So I kind of grew up with it. But even if they say they have broken mirror neurons, they are looking. Especially kids with autism, they look at people's mouths. And so if they're not seeing people eating and drinking typically, which I will give people guidelines with what that should be.
[00:45:16] So the first thing I hand to the parents is, let's practice everybody eating and drinking technically. So you can be good role models. So we have to look at the family and what's going on and how they're eating and this is not to put the family on the spot. I go in and I fit in with what the family's patterns are.
[00:45:39] I don't try to, I mean, yes, do I want them eating and drinking together when they can, but we look at their schedule. So here in Las Vegas, you know, we have people that work all kinds of shifts. So, I look at what's practical and I'll work with grandparents. So I, I, we, we've had some very, very good nannies and our ABA people because they're seeing the kids in their programs every day.
[00:46:05] I've gone right into those programs and work with them during snack times and lunch times and all of that. Everybody, I have the. The facilitators eating along with the kids. They have to have lunch too, right? 
[00:46:21] Madi Metcalf: Absolutely. 
[00:46:24] Diane Bahr: Involve the child in shopping, food selection, and discussion and preparation. Babies can ride in those grocery carts and parents can talk to them about what foods they're picking up.
[00:46:36] So even a six month old baby can pick up the broccoli and the asparagus and say, Oh, which one should we take home? And whatever, when the baby looks at, that's the one you're going to take home. Even shopping online, as we've started to do a lot with COVID. The parent can say to the, I don't want the child and parents sitting in front of a computer, but if the parents shopping, maybe they look at some of these shopping items and say, what should we order, you know, because my daughter still does that because she has three kids.
[00:47:12] She still orders, picks up her orders, and she lives in a small town. So it's real convenient to do that. So preparation, I don't want you sitting your baby in a high chair and making them sit there through the whole preparation, but you can have them in the high chair, for example, when they're young, and if they're safe, experiencing some of the foods that you're using in preparation, you know, and then they can play while you're cooking them.
[00:47:44] But as soon, so we had A lot of our kids at the school for the blind were very had multiple handicapping conditions and a lot of cerebral palsy of all ages. We didn't have a lot of typical kids. They were the tip, even though they were visually impaired, those kids went to the regular schools. So what we did, and the same with Ian his assistant.
[00:48:10] Took him down to the kitchen at their school, and as he increased his texture and the foods he was eating, he was doing, and of course he was 17, he was doing that food preparation. So even the kids with cerebral palsy, we had switches. We used to make our own switches. Linda Burkhart taught us how to do that.
[00:48:31] But we had switches that could run Blenders, you know, if we were making that whatever, and then Suzanne and Marsha, even for two kids, we got our first two kids when I was working there. 
[00:48:47] Madi Metcalf: Oh, wow 
[00:48:48] Diane Bahr: G tube kids and, so, at the time, they didn't have G tubed formulas, and people were clogging up tools because, tubes, sorry, not tools, tubes, because they weren't blending them properly.
[00:49:05] And so, Suzanne and Marsha, along with some others, created this homemade blended formula cookbook when you're moving kids from tube feeding to oral feeding. Because, one of the problems we find is, The kids aren't used to having regular foods in their stomachs. And so, and of course, they're not used to having regular foods in their mouth.
[00:49:29] So let's talk about smell. If you can't breathe through your nose and you can't smell food, what's that going to do? So for Ian, he couldn't smell anything he was eating. Now, think of yourself. If you don't like the smell of something, are you going to eat it? Oh, very hard time. What if you've had a cold?
[00:49:52] Madi Metcalf: Yeah. 
[00:49:52] Diane Bahr: Does it change the taste of food? 
[00:49:54] Madi Metcalf: Yeah. 
[00:49:54] Diane Bahr: Everything is super muted and I don't enjoy it nearly as much. And it can impact my appetite if I'm like really congested. 
[00:50:01] Absolutely. So, and it changes your swallowing, too. And the back and base of tongue is where we see the most problems. A lot of our kids who are getting tongue releases just do not have good back and base of tongue use, which is why we do bilateral chewy tubes, yang, yang, yang, yang, yang, as an exercise.
[00:50:26] And then, of course, we work to get the foods back safely, whether it's in a safe feeder or when they're ready, like Laurie Overland in her book talks about the upside down cocktail for, I mean, we've all learned from one another over the years, thankfully and have shared this information. So, smell and taste work together.
[00:50:50] Oral defensiveness or defendedness, as Suzanne calls it, we need to work through that. We can't, we can't just have kids pushing things away and then say, okay, we're done. Because when you do that, they take that as a yes, we're done and I don't have to do that. I went to massage school instead for two and a half years and became a fully qualified and just because I wanted to learn more about the body and how to work with body.
[00:51:26] And so the school for the blind, when I got there, had an oral massage process where you work on the arms up to the face toward the mouth. But the thing is, with oral massage, you can do that during tooth brushing. So I had one mom who actually lived down the street from me in Maryland, and she had two boys on the spectrum.
[00:51:47] And I would treat them before I went to my office. And so, she did the tooth brushing work with them and made sure they got the stimulation in the cheeks, the teeth, the gums, the tongue. I didn't have to do oral massage. They just came down ready. For me to be able to touch them, of course, you have to gain trust and that's really important.
[00:52:14] So anyway the changes have to be very small and systematic over time, as we've already talked about. We don't force feed and we don't use punishment. And so we need a consistent behavior modification program that is going to fit into the natural world of the child. So we had social stories for Ian that prepared him quick, that he would read with his assistant or his father.
[00:52:47] And then we had reinforcements that we used very carefully. So if he is eating when you watch him on the video in the speech therapy PD one, I mean, You guys, if you take that course or you have taken it, you'll see I have still a lot to learn. I learn a lot from watching my videos. But the thing is that we have to learn to balance all of that.
[00:53:17] So I had children who had gone to feeding programs for punishment. Had actually been used, and we don't do that. I don't know of any cleaning program that does this now, but way back I had kids come back from programs where squirt bottles were used, like they use with cats. Oh my goodness! And then also You have to use your variations on the theme.
[00:53:46] So they, and I'm not criticizing those feeding programs. They were doing the best they could at the time. They were behavior modification program. And so they didn't have speech people. They didn't have OTs. And so they were using good. I mean, I come from a behavior modification background. That's, that's how I was trained to so that we were chipping kids to death.
[00:54:11] Yeah. For good speech at the time, very bored. But the thing is so what happened in some of those programs is they would find ways to feed kids, but they fed them only one way with what like the parent could only feed them one way. So they didn't have generalization. So by using different cups. By using slightly different spoons, but appropriate, not tablespoons by using different types of straws and things when we get to straw drinking we are getting generalization by drinking from different drinking bottles, for example we get generalization, and I'm not going to talk about Reducing tongue thrust and all of that, that's another topic, but we need appropriate foods and liquids beginning at birth and at birth.
[00:55:10] It's your formula or and or your breast milk and a lot of moms are having trouble with breastfeeding these days and that's because baby's mouths are not the same as they used to be. And so. We'll go into that just briefly, but before we go there, in my books, I have, and I know you're not going to see me on video, but Maddie can guide you, and I could even create a handout, or you Just contact me.
[00:55:46] I have a bunch of handouts that I did for the Breathe Institute for others. You tell me what you want to work on and I'll, I'll send you a handout. The one I did for the IOM kind of covers everything from in utero up. So, and 
[00:56:00] Madi Metcalf: they're super amazing guys. Definitely reach out if you're interested. 
[00:56:04] Diane Bahr: Yeah. Yeah.
[00:56:05] You know, I own my things. So, I'm not going to give you the speechtherapyPD. one, because you're going to get that there. The other courses I've taught for Northern for talk tools for others, but the ones that I own, because I only taught briefly for PBI to help them get started. You know, I have those, so you asked me for something and, you know, I send it and I don't want to overwhelm you as a therapist.
[00:56:34] So. Don't send me your cases. I'm not mentoring right now for payment and I'm not treating right now for payment because I have these two other projects I have to get done. But I will be back to that because I love to treat and I love to mentor so appropriate foods You'll see I haven't asked your presentation I can share with you that Christy Gatto and I did and it has six to eight months nine to twelve months eighteen to twenty one months about how much a child should be eating by age and and then what the feeding delays and differences are.
[00:57:11] And so, a lot of times it's just that the parent or the therapist hasn't gotten the information they need for what they're doing. And I'm not saying you're not well trained. But a lot of you contact me and say, who should I take a course from? So my course started at Loyola University. It was a full semester course in feeding and swallowing and oral sensory motor work.
[00:57:39] And we had three freestanding clinics where our graduate students who took the course could practice this. With us, 
[00:57:50] Madi Metcalf: I wish I could have had that in my graduate experience. 
[00:57:54] Diane Bahr: So, and most people don't, but I have a lot of people who are teaching grad school, who actually use the books. Or especially the 2010 book.
[00:58:05] Nobody ever told me or my mother that because they just want people to know normal. And that's what I mostly teach is normal. And so when somebody is off track, I look at where they should be normally, and I work to get them back to typical. And if I can get a baby from birth. So I had four. I worked with four lactation consultants in Maryland and I have a couple here.
[00:58:31] If we can get them on track from birth, then we can often avoid a lot of the defensiveness and if a mom is having trouble breastfeeding, if we can get appropriate treatment with the mom and baby working together. Where mom feels successful. Because the moms are frustrated. They aren't like me. I stayed home.
[00:58:54] My friends stayed home. You know, if my daughter needed to nurse all day and I laid on the sofa and sideline and watch TV while she was nursing, because she has low muscle tone as I do. It runs in my family. So we're on the low side of normal, but I was able to successfully breastfeed her. And introduce foods on time because I knew what they were but a lot of people are frustrated.
[00:59:23] So I had a therapist contact me on text over the weekend, and not everybody texts me, but this is one I know well. And she had a friend in another state who was really frustrated. So the baby's going to pick up on that. So let's find what people can do and be comfortable. So back to let's talk quickly about ties.
[00:59:47] So you're going to introduce. Sensory motor activities on time. We're going to keep the airway clear from birth. We have ways Nosy Frida and that kind of thing that we can use with babies to do that. There are fun ways with a nasal mirror. You can teach a kid to blow the nose. It's a little messy, but But hey, it's there.
[01:00:14] I, all my clients have their own tools. And I keep the tools limited so the parents and children aren't overwhelmed. So let's just talk about ties. I talked with Suzanne about this. And so I had a pediatrician who's a holistic pediatrician come to me, and I had one of the top IBCLCs in the nation who happened to come here and teach, and I've known her for a long time.
[01:00:44] And both of them said to me at about the same time, a few years ago, Why are we seeing so many babies being born? Born on the low side of muscle tone. So the pediatrician thought it was metabolic, because those ties are being maintained and they should be resorbed. We never, I asked Suzanne, because she's been in this a lot longer than me, I said, You know, we've been in baby's mouths, and it's not that we missed the ties.
[01:01:14] So, since pretty much the beginning of our careers, and she started out, like, in NICU. So, we didn't see all the ties we're seeing now. So, what, what is happening? Well, we have a lot of children, apparently, based on what the pediatrician and the lactation consultants tell me, being born on the low side of normal muscle tone.
[01:01:40] We have these tissues that are supposed to be resorbed and Dr. Gimeno's work is some of the best on it. And I work with Dr. Serge Zaghi as well, who trained under Gimeno and also at Harvard and also at Stanford. And. And so, we have to wonder, it's just a question. Are those ties staying in place to keep the structure together and not being resorbed because otherwise the structure wouldn't have stability.
[01:02:16] So that's what Suzanne said. So, you know, this pediatrician who knows all about metabolic, metabolics may be right because there's some reason they're not being resorbed. So maybe the low tone metabolism is there early on, because we seldom saw buccal tie. And we saw the stringing anterior tongue tie.
[01:02:43] And if you look at Kate in either the speech therapy PD course. Or we look at her in the free little e course I give, you'll see she was brought to me because they thought she had a tongue tie. It turned out she, she just needed her mouth organized and she needed to learn to cuff her tongue. And so that's about we've used an hour and 5 minutes.
[01:03:12] So you guys can You know, do whatever you want with this video and audio and, you know, dibahr@cox.net
[01:03:27] and ages and stages registered trademark. We actually have the original trademark on ages and stages LLC. So we're not this, we're not the test. And you know, Just be patient with me. I look at my email every day. And if I can't get back to you, I tell you when I will get back to you. Just don't send me long emails with long cases, because then I'll refer you to someone else like Nina Johansson.
[01:03:58] Who actually still does, you know, a lot of that mentoring, teaching in group. So I was her mentor. Now, you know, she is. Fabulous therapist and I've worked with so many other fabulous people. I can't even begin to name all of you. So forgive me. And I've also worked with fabulous speech scientists. So, in my new program, we will have their names listed.
[01:04:27] Madi Metcalf: Awesome. So, for everyone that was listening, your website, which is fabulous with so many amazing free resources is agesandstages.net. And your email is D I B A H R at Cox. net. This has been such an amazing talk, Diane. Thank you so much for giving me an hour of your early morning time today to go over this.
[01:04:52] Maddie. It was a pleasure having you on to kind of talk more about that feeding skill and the importance of proper oral motor and sensory development and how that supports feeding and can relate to selective eating. 
[01:05:04] Diane Bahr: Yeah, and Maddie, I have to thank you, because you are so active. I have your, I don't think, oh, I do have your bio here, but for everybody who doesn't know Maddie, she nominally is doing these podcasts.
[01:05:23] But she's very active in her local speech. I was too in Maryland Speech Language Hearing Association, and she's also a volunteer this year for the International Association of Oral Facial Myology and she and my daughter, Kim, Who also has a second master's in I. T. We're just helping the executive director of the island yesterday.
[01:05:52] So we're, we're very lucky. We have 10 volunteers from the area of speech language pathology are our conference. We'll be international with people from all over the world. And it's at least half SLPs presenting. So we have people, one from Cairo, one from India, one from Australia, one from the UK plus our own people here who are wonderful.
[01:06:22] So if you're in North Carolina or somewhere nearby that's in September and we'd love to see you there. 
[01:06:30] Madi Metcalf: Awesome. Yes. Check out the IOM conference for sure. They have a really awesome lineup. Well, thank you everybody for tuning in for another episode of making sense of selective eating. As a reminder please complete all the sections on the course content page, including the quiz to get your CEs on your speechtherapypd.
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