134 - Feeding White Flags: When to Seek Support with Speech Pathologist Emily Tyler

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0:17Emily Tyler:You're listening to Boob to Food, the podcast with Luca McCabe and Kate Holm.

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0:47Emily Tyler:can confidently navigate the roller coaster of motherhood from boob to food and beyond. Each week you'll hear practical wisdom, expert advice and inspirational stories of other mums in the depths of this parenting journey. Let's dive in. Today's episode is brought to you by Part and Parcel. Welcome back to Boob to Food, the podcast, and welcome back to the podcast, Emily. We're excited to speak with you today. As always, you're a wealth of knowledge on so many topics, but today we want to speak to you about some of the white flags when it comes to feeding and our little ones. But before we dive into that topic, can you just share a little bit about who you are and what it is that you do.

1:25Yeah, thank you for having me. So I'm Emily and I'm now speech pathologist at Boob to Food and I am a speech pathologist working and living in the southwest of Western Australia. I work mostly in the zero to five population supporting feeding and early language but currently on maternity leave with twin girls and a little toddler that's keeping me very busy.

1:48Emily Tyler:I can't believe your twins are 10 months, by the way. That has gone very, very quickly. Because we, I think, recorded a podcast, what, about a year ago now? Well, you were pregnant. Yeah. Yeah. It's crazy. Now they're very much here and making themselves known. And so for those listening who are wondering, what is a white flag? Can you just explain the concept of what a white flag is when it comes to feeding and how it might differ from a red flag? Yeah. So I use the term white flag because I think that in the parenting space, there's always so much fear and everything's so alarmist. And I think there are spaces where that's really warranted.

2:27So a red flag in feeding would be if your child is at risk, you know, like as in their safety is compromised and they're at risk of, you know, injury or illness or anything like that. That's certainly a red flag. But a white flag would be more where there's difficulties in place. You don't sort of know necessarily what's causing them, even if they're within normal parameters, but you feel like you can't do it on your own. The white flag was just sort of raising a flag to surrender and go, I can't do this on my own. And just I feel like mothers these days, mothers and fathers, are taking on so much, you know, from sleep and feeding and all of that.

3:07And you don't have to go at it alone if it's more challenging than it should be, which is kind of my crux for everything. If we talk about any white flag pertaining to infancy or toddlerhood, if mealtimes are harder than they should be, that's enough of a reason for you to reach out and get support. It doesn't have to be a battle.

3:24Emily Tyler:Yeah. Even like, I feel like even if mealtimes, you just have a question, there's any time you're like, I'm not sure about that, even if it doesn't feel overly challenging. It's so good to outsource. And we talk about this all the time, like you say, across a variety of topics, like parents have enough on their plate. it's okay to reach out to the professionals who might be able to give you a quick answer or might say yes this is something that warrants further support and I guess when it comes to the feeding space and sort of that you know six to twelve months when we're starting solids what might indicate that a child could benefit from some further support?

3:58So six to twelve months is a pretty big range so I'll sort of break it down in terms of when you're starting solids everything is a little bit more slow going. We've touched on it before, but it is really normal to have a little bit of gagging, messiness, spitting, spoon refusal. All of that stuff is within normal range when we're first exposed to solids. So I would think that if you've been going at it for, general rule of thumb is about that eight month mark. I think if you're still having a lot of difficulties at that eight month mark, then I would reach out then. But I would look at refusal of solids or like difficulty transitioning to solids at all, if they're really preferring the breast or bottle.

4:44If we're getting lots of distress during mealtimes, so it's just, you know, as soon as you go to put them in their high chair, they're flipping out or whatever it is. Vomiting on solids, if they're not being able to keep their food down. If you notice that their chewing is really challenging, so, you know, they're dealing really well with the purees, but as soon as you introduce anything that is either a lumpy texture or requires a little bit of prep, if they're not coping with that, again, keep in mind that it takes a few exposures to know whether it's just normal developmental progress or whether it's something that's going to be ongoing.

5:18Frequent coughing or choking during their meal, definitely choking if they've choked, you know, at all. You'd probably want to make sure that you're modifying the food to be a developmentally appropriate texture or you're checking that they're, you know, developmentally ready for solids. If they've got ongoing food refusal, so even, you know, even on puree or anything, if you're noticing that you sit them down in the chair and they're not taking anything at all. If they've got, I've sort of touched on that, but a preference of puree over soft foods if you're not seeing that progression. And if mealtimes are just a battle, like if that could be because the little one is making it harder, you know, unknowingly sort of thing, but they're not happy, they don't feel safe, they're in distress.

6:07Or it could be, I've worked with a lot of families where the mum's stress and worry is making the mealtime challenging as well, which is very warranted. It's a scary thing when it comes to feeding your little one. So as soon as the, environment feels uncomfortable or yeah, it's causing distress in anyone involved, I would advocate for raising that white flag. So you mentioned about persistent gagging or spitting. What's typical versus what might need support? Because a lot of little ones will do a lot of gagging or spit things out, but how do we know when it's not normal? So there's kind of two main approaches when we think about starting solids.

6:47And obviously here at Boob to Food, we advocate a lot for baby-led weaning. So in that case, when we're starting with more solid foods from the start, we would expect to see a lot of gagging early on. So we spoke about it on a previous podcast, but little ones when they're quite young have their gag reflex almost at the tip of their tongue. So they could be gagging as soon as a nipple's presented or they go to put something in their mouth and they gag right away. Over time, with either mouthing toys or with food exposure, that gag reflex moves further and further back to become that protective mechanism that is a really good thing where if anything goes prematurely to the back of the throat, we gag, our muscles constrict and propel it forward.

7:28And that's what keeps our airways safe. So in a baby led weaned little bubba, we would expect to see quite high gagging at the very start and then over exposures, we'd see that decrease. So, I mean, complete generalization, but I'd say that six to eight weeks sort of mark where you're pretty engaged in solids they've had a lot of exposures um i'd expect to see it certainly start to come down but definitely not worsen so you might see it a little bit persisty but you'd expect that to come down a little bit in a little one that's following the more traditional model of purees mushy you know mashed up food soft finger foods that sort of thing we usually see it as a delayed gagging so you'd where the food's been introduced at six months but they've been on puree we'd see the excessive gagging there for a baby led weaned but for a traditional modal sort of one we're seeing that more about that nine month mark when the soft foods come in so we see it later um sometimes parents want to avoid soft finger foods because they think oh no I don't want to cause gagging you're always going to hit that mark not always sorry some children randomly don't gag my one of my little twins doesn't gag much but you usually do see that eventually when the foods are introduced but I would say around that for a traditional approach around that nine month mark give it I don't know a month maybe and if it's still persisting and worsening then I'd get some support and for a little one that started on solids, I'd give it a couple of months there.

9:04And is it true if they're gagging before the food has hit their mouth that that is a sign to seek help? Yes, yeah. So there's a number of reasons. So there's about four different types of gags. So we've got a hypersensitive gag, which is where they just have an overreactive response. So someone that brushes their teeth and gags or hears vomit and gag sort of thing, you've got that hypersensitive response. There's motor-based gagging, which is where they might have poor control so that the food might move prematurely to the back and cause that, so it's because they're not able to control the food.

9:40Sometimes they can use it as a means of communication. Babies don't yet have language, so they can sometimes use it, be like, I do not want that, get it away. And, yeah, there's structural gagging as well, which is where something's going on structurally. They're a lot more rare, but you might have something going on with the esophagus or at the back of the throat that's causing that gag.

10:01Emily Tyler:We'll be back after this short break. Today's episode is brought to you by Part and Parcel. I feel like no mum enjoys taking the kids to the supermarket. I definitely do not. And so being able to order everything online and have it delivered to your door is just such a blessing, especially when it's all products that I absolutely love. If anything, it's a little bit too dangerous and I could buy one of everything. Absolutely. My biggest hack, I think, when it comes to cooking healthy meals for your family is to have a well-stocked pantry. And I love that Palm Parcel makes this really easy for me.

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11:22Emily Tyler:Now let's get back to today's episode. What does it mean if a child is pocketing food and why might that be a white flag? So pocketing is the term we use when children are sort of squirreling it in their cheeks. So usually it goes hand in hand with overstuffing. So they're putting too much food in their mouth. Sometimes they can lose track of it and store it in their cheeks. It would be a white flag because ideally we always want food to go towards the tummy. So as soon as it's in the cheeks, I would be questioning there could be a sensory component and they can't feel that there's food in there and they've lost track of it over the meal and it's just being stored there unknown to them.

12:04It could show a motor difficulty where they're not able to chew it up efficiently enough and therefore it's falling to the sides and they're not, they don't have the control or the tongue mobility to be able to get it back and prepare it properly. So that's why we'd be concerned at that. There's a number of strategies that we can do and I'm sure Rach, our OT, would also have a lot of strategies as to presenting the meal and things like that that could reduce pocketing but from a functional point of view they're probably the two biggest things that I look out for. My youngest son, I don't know if it's called pocketing but it used to always get stuck on the roof of the mouth.

12:38Is that different though? Because I feel like he would just get stuck there, not that he was putting it there. Yeah and for some kids, pocketing in their cheeks is them, like it's not necessarily them like knowingly being like, I'll save that there for later. They'd lose control. But, yeah, more the roof of their mouth. We see that in a lot of kids with high palates as well or when you're introducing them to foods, like if you gave them toast with peanut butter or something. Yeah, something sticky. We'd get the sort of foods that you'd get started. Oh, it was so many things for a while. He sort of just grew out of it but it'd be so funny you'd give him a meal and then you'd whatever and then you'd go to put him down for a nap and you'd look in his mouth and think, oh, my God, there's like a whole lamb up there.

13:16Pull it all out. It was so random. I'd say maybe a higher arch or something like that. He grew out of it, thankfully, but it always would shock me. That's so funny. It is, yeah, so it's still, I wouldn't think of that. Like if a parent told me, oh, my child's, you know, used the term pocketing or if they said they're stuffing it in their cheeks, it would more often be that that I'd hear because there can be a behavioural, not behavioural component, but I guess it's a lot more common that we'd see little ones have difficulty with a meal, it'd end up in their cheeks and them not notice or not be able to get it out, whereas I'd say there's a lot less voluntary control when it's, yeah, getting stuck in the roof of the mouth.

13:57Yeah, because when you think about it, we use our tongue to sort of remove that food, don't we? So if he had his little tongue tie that he did have, which we've talked about in another episode. So that's a technique that sometimes we use is at the end of the meal you might get your little one to use their finger and hook in and get the rest of the food. So I know we say, you know, don't put your fingers in their mouths and things, training them to do that can be really supportive. Sometimes even something as simple as like presenting an empty spoon so that they open their mouth as they go and narrow.

14:27I just can't open my mouth again. No one can see. So as you open your mouth, it narrows the cheeks in and it could make the food fall to the centre and then they have another go of it.

14:36Emily Tyler:And what about like an ongoing tongue protrusion? Why is that something to look out for? So that could be going on for a number of reasons. There's no, like some people, we definitely spoke about this on a previous podcast, I remember, because my husband still has a tongue thrust swallow. So some adults still, you know, they have a tongue thrust swallow their whole life and that's nothing to be, you know, worried about. It's only when it is impacting and let's just say that tongue protrusion means that we're not able to get any solids into bubba. The reason that we look at it is, I guess, because as a speechy, I'd be questioning or why is that happening so we see it sometimes in kiddos that have low tone so low muscle tone so even in things like down syndrome we see that tongue protrusion stay around a little bit longer because muscle tone's an issue for those kids we sometimes see it in kids with respiratory difficulties so if you think of those kids that have difficulty with their airways and their mouth breathing we often see that more forward position of the tongue so that would make me want to partner with potentially like an ear, nose and throat specialist or something like that, just to make sure we don't have enlarged tonsils, adenoids, anything going on structurally that's making that tongue position forward.

15:49It could be a postural thing. So if they're not sitting appropriately in the chair, they might have hyperextension of their neck, which is causing their tongue to sit in a different position. And it could also be that the baby's just not ready. So it's certainly, and we, yeah, we touched on this in a previous one, it's not a sign alone that would make me not start solids with a kiddo, but it could be something to keep an eye out for and just start a little bit more cautiously, I guess, with the progress and introduction of solid foods with that little one.

16:21Emily Tyler:And what about signs in the parents? If like feeding seems to be going well from the child's side, but mum and dad or whoever the caregiver is, is feeling stressed or anxious, what are the white flags that the parents should be raising or what do you see on the parents' side of the equation? Fear. So a lot of fear and anxiety around mealtimes, you know, postpartum is such a sensitive time for so many mothers and fathers anyway. But if mealtimes are exacerbating that and they're feeling like they can't progress their kiddo, if they feel like they're the ones holding back their kid's progress, I would certainly reach out.

17:02I only had a phone call with a mum last week actually who just wanted to have a little bit of a chat because she didn't feel like she had a good grasp on you know is she's like my little one doesn't even have teeth how can I start this like it seems so crazy and it does feel so counterintuitive sometimes. So just understanding I guess the physiology of it can sometimes be enough to reassure parents. I always say that making sure you've got adequate at safety training behind you. So as a parent, I think it's crazy that we get given these babies at hospital when there's no like pre-interview or anything like that.

17:37But I'd say doing something like an infant first aid training or something that makes you feel confident in if anything did go awry because things can happen all the time beyond our control and we do everything within our power to keep our little ones safe. But making sure that if things don't go well, making sure we feel like we can handle that. And then the next thing would be making sure you're educated. So definitely following along to Boob Food and following our resources and things like that can make you feel a little bit more empowered because making sure we're offering developmentally appropriate foods to our children is one of the most, you know, safety-enhancing things that we can do and make sure that they are progressing as we expect them to.

18:22But, yeah, I'd say if mum or dad are coming to the meal, and within reason like I'll be honest for the first two months of the twins life I had to solely feed because my husband was like this is you like I can't do this and so he was just finding that as soon as they gagged it was causing quite a stress response in him and I know Rach did a really great reel on our page where you know if the little one's looking at us and all they're seeing is this look of terror that's not going to contribute to an overall enjoyable meal times and one of the biggest things that I know you guys advocate for is the the joy of family meals so that starts with everyone at the table being comfortable.

18:59And what's your advice for a parent or a caregiver who's been told to just wait and see, but something just doesn't feel right? Shop around. I think that it's so hard and you touched on it in a previous episode, Luca, but you know, there is a real luxury and privilege to be able to shop around or to be able to ask around and get a second opinion, those things all cost. And so it is really hard. So you obviously do it within your capacity. But finding health professionals, whether it is someone, you know, someone like myself, and I'm not sort of self-promoting, it could be anyone, but a speech pathologist who you align with on Instagram or a feeding therapist that you've found through whatever networks, even being able to feel like there's a place where you can ask a quick question, that could be really helpful in just reassuring.

19:52um I certainly wouldn't if mealtimes are harder than they should be for any party then it's worth continuing to pursue and advocate for your family like there is obviously there can be um a lot of anxiety unfounded anxiety in parents but that still needs to be addressed because that's a bigger part of the feeding picture as well um so it might not necessarily be that your little one it's not your little one that's a cause for concern but we still want to address that anxiety in the mum regardless. Hope that makes sense, but yeah.

20:22Emily Tyler:And is there any harm in getting support early? I would always advocate that there's not. I think that being ahead of the curve, particularly when there's wait lists for a lot of services and things, when we've done our Q &As on food to food, I feel like a broken record because I'll constantly be like, but if you're concerned, you know, refer now. And if the appointment comes up and you don't need it, they're wonderful and if you do need it you're ahead so um you know the services both public and private are there for a reason and they're to make your journey easier so I'd certainly make the most of them and yeah utilize them when you feel like you need to but it's like we always say you also have to trust your intuition and a lot of feeding journeys aren't linear you know a baby might start solids and kind of be doing really well and then they might go backwards for a little It'll be it'll just plateau and then they might go well again and it's sort of – it can be really stressful because it's not really like a black and white kind of gruff where they keep going or progressing.

21:21Sometimes they'll be like, oh, all of a sudden I don't like that texture or that food and you think, is this normal? Is this a developmental thing? Is it teeth? It's always teeth. Yeah. Is it teeth? Do they not like the food because of this or they get sick or whatever? There's always so many things. But I think trusting your intuition, if you think something's not right, Just getting a second opinion, raising that white flag, like you said, before it gets to a red flag, before it gets to, you know, an issue with weight gain or dehydration or that they're not eating or whatever or that you've spiralled into an anxious mess is what the message that we're trying to convey here is.

21:57There's never harm in reaching out for help, even if that's just speaking to your GP, getting that referral, having a second opinion. And, yeah, finding people that you align with. on this one good thing about social media sometimes you can sign yeah absolutely and I think and I'm gonna do and I'm not involved in the book so I can do a shameless plug but your books are really really helpful for that because they give so much information for first-time mums we don't have a basis for you know what's normal what's not and you know you guys might go oh well I saw that in my firstborn and eventually cleared up but for a firstborn for a first-time mum that can be really anxiety provoking um so particularly the toddler to table book there's so much there that I've recommended to families that I've, you know, sort of supported has been look for those things in there because they tell us so much about, you know, the normal picky eating that comes up and that can be your basis for, I guess, comparison when you don't feel like you have that from your own life experience.

22:56Yeah, well, toddlers are another whole kettle of fish of stress. Yeah, you're always wondering, you never know. I think everything in my parenthood life has been. It's just developmental or it's a phase. You're just praying it is every time. It's like Will's bad sleep. It's a phase. Like he's four soon. It's a long phase. I don't know if it's a phase.

23:20Emily Tyler:Oh, thank you, Emily. It's always so beautiful to have you on the podcast and so reassuring. And I think, yeah, if anyone, you know, needs just one take-home message, it's if you're ever feeling concerned, no matter how big, no matter how small, no matter how silly you think it is, it's not silly. Just reach out for help. It's always great to outsource that stress and that worry and get an opinion from someone who is trained to do it so that you don't have to spend hours and hours trying to research and understand what's out there. So thank you again for sharing with us. You're so welcome. Thank you for having me on.