Conan Gasque (Host): Welcome to inside Pediatrics, a podcast brought to you by Children's Hospital of Alabama in Birmingham. I'm Conan Gasque. Our topic today is Feeding and Language Development. We're speaking with two members of our hearing and speech team about some of the issues parents might encounter as their child is developing.

We're talking to Emily Swindle, inpatient Speech Pathologist here at Children's and Meredith Street, outpatient Speech Pathologist, also here at Children's of Alabama.

Thanks so much for your time today.

Emily Swindle, MS, CCC-SLP: Of course. Thank you.

Host: So Emily, we're going to start with you and we're going to take a little bit of a look at feeding first. We'll have a few questions about that. Uh, obviously a very big issue. One of the first things that a child learns how to do. What do parents need to know about feeding specifically in the first year of life?

Emily Swindle, MS, CCC-SLP: Um, yeah, so the first kind of thing that a baby learns how to do is feed of course. And, um, I think the most important thing to know for parents is that all of their nutrition in the first year of life is either going to come from breast milk or it's going to come from formula. Um, and so, you know, we obviously start introducing some solids and things later in the first year of life, but a lot of times parents, can get confused about what exactly their baby needs for nutrition and it, it's all going to come from that breast milk or um, formula. And there's really, you know, not a right or wrong answer in terms of like whether they should do breast milk or formula. It's kind of parent's choice and what they have access or ability to do, but that's where they get all their nutrition.

Host: And even if it is breast milk, sometimes it's coming from the bottle.

Emily Swindle, MS, CCC-SLP: Yes.

Host: Um, it might have be pumped, might have been pumped milk. So bottles are a key issue for sure of something that you know, that, that parents need to understand. And one of the details is flow rate. What exactly is flow rate?

Emily Swindle, MS, CCC-SLP: So flow rate has to do with how fast the milk is coming out of a bottle when a baby is feeding. Um, and a lot of times parents don't know that every bottle company kind of has a different version of a flow rate. Um,

Host: It can be confusing.

Emily Swindle, MS, CCC-SLP: Yes. Very confusing. So, uh, they kind of just assume that every company's level one is the same, but that's not necessarily the case.

Host: Is that just a matter of kind of doing some research to make sure, you know, here's level one for this company, here's level one for that company.

Emily Swindle, MS, CCC-SLP: Yeah, so for us speech therapists, we kind of have some research that we have access to that gives us information about how these different bottle flow rates compare to one another. But I would say for just the average parent, um, some things that they could know to, to figure out if it's too fast. Um, there's a couple of things that they can look for, um, to know whether it's coming out too fast for their baby.

Host: What are some of those things they need to watch out for?

Emily Swindle, MS, CCC-SLP: Some things that they could watch out for. Um, is any kind of spillage coming out of the front of their mouth when they're drinking. Um, any kind of like loud gulping while they're drinking? Um, I typically say that a baby should take about one ounce every five to seven minutes is a good pace. Um, and we want them taking their full bottle within 30 minutes. So if they're taking like six ounce bottles within five to seven minutes, that's way too fast. It's like fire hydrant. Um, so we want to slow that down a little bit, um, which can help us with some things like reflux and coughing and choking on the bottle as well.

Host: Are there any concerns that a parent should have about, uh, you know, taking the milk too fast or too slow, can that lead to problems for the baby?

Emily Swindle, MS, CCC-SLP: Yeah. So, um, sometimes I feel like babies who have really bad reflux, they can benefit from reducing that flow rate a little bit. That's usually our first line of defense. Um, and then the other thing that can happen is, we can have some aspiration, which for those who may not know, aspiration's just a long, fancy word for, uh, liquids going down the wrong way into the lungs when a baby is swallowing. Just like when we eat too fast or drink too fast and we get choked and we say, oh, that went down the wrong pipe. Yeah. Um, can happen to babies as well.

Host: Is there anything that, um, a parent can do to kind of prevent aspiration? Is it, and, and I guess that goes back to the flow rate, making sure you're having the right one. Right?

Emily Swindle, MS, CCC-SLP: For sure. Yeah. So one of the first things we usually look at is flow rate. And so if a baby is having some signs of aspiration, any kind of coughing or choking on the bottle, any kind of chest congestion with feeding, um, difficulty breathing or eye watering with feeding, those are all kind of signs of aspiration. And what we typically do is decrease the flow rate first, um, and see if that improves some of those symptoms.

Host: And the flow rate also changes over time as they get older, right?

Emily Swindle, MS, CCC-SLP: Mm-hmm. Yeah. So I typically tell a parents that if their baby is getting frustrated, um, because it's, they're working too hard to get that formula out, or it's taking longer than 30 minutes for them to finish, that's when you would want to increase to the next higher flow rate.

Host: I know sometimes we hear about bottle aversion. I want to talk about that a little bit as well. How can, what does, what does a parent need to do if it appears that their child just doesn't want to take the milk?

Emily Swindle, MS, CCC-SLP: Um, well the most important thing is to remember that we want baby to be happy and comfortable during feeds. So we prioritize cue-based feeding and encourage that with our parents here at Children's. Um, that just means that we follow the baby's lead in terms of their interests in the bottle. Um, bottle aversion can look as simple and small, uh, as like I just refuse, after a couple ounces, I'm just kind of satisfied and done. Um, or it can look as significant and severe as like back arching and head turning and crying and gagging on the bottle. And so we kind of want to be on the lookout for those signs.

Host: And that can affect their development, I imagine.

Emily Swindle, MS, CCC-SLP: For sure. And they're weight gain and nutrition.

Host: So, uh, when can a parent start exposing their child to foods other than formula and the breast milk? When, when does that kind of, that process start?

Emily Swindle, MS, CCC-SLP: Yeah. Every baby's different. Every baby's development is different. We tend to kind of look at their overall development and their milestones, uh, instead of a certain age. I would say generally five to six months is a good time to start looking at kind of transitioning to purees or um, things of that nature. But we obviously want the baby to be sitting independently, kind of having some good head control, sitting in a highchair. And that's kind of when I would start introducing those things.

Host: Any advice on, uh, managing that transition? Uh, I, I know it can be a little tricky.

Emily Swindle, MS, CCC-SLP: Yeah, a little tricky. Um, babies obviously have never put anything other than milk in their mouth, so it can be a funny experience to see their first face after their first try of a puree. Um, but we just want to continue to keep it positive. It may take several introductions to a puree or a flavor for them to really get used to it. Um, and we just want to take it slow. And again, that positive cue-based feeding experience.

Host: How about when you're going from purees to solid foods, uh, what parents need to know about that?

Emily Swindle, MS, CCC-SLP: Great question. Um, yeah, I think we want to take it at the baby's pace. So if baby's doing great with purees and you want to introduce some soft solids, um, I would start there. If a baby starts having some difficulty with manipulating that or a sensory, you know, experience where they start gagging, I would kind of take a step back and go back to purees for a little bit longer. Sometimes the difficulty can be more sensory related, where they just don't like how it feels in their mouth, but sometimes it can also be more oral motor related where they have difficulty chewing or, or weakness that makes it harder for them.

Host: Is there a point where if your baby is having trouble feeding, you need to get medical professionals involved?

Emily Swindle, MS, CCC-SLP: Definitely. So if you are seeing any kind of coughing and choking or signs of aspiration with your child when they're swallowing with a bottle or when they're swallowing with a sippy cup or a straw, or even with, um, solids, I would definitely talk to your pediatrician first. Let them know your concerns. And, um, if the pediatrician agrees that there is some investigation that needs to be done, then I would have them put an order in for either an outpatient speech evaluation or a swallow study.

Host: All right, very good look at, uh, feeding and what parents need to know as their child is going through that process of, uh, developing from a feeding perspective. I want to take a look at language now. So we'll bring in Meredith Street outpatient Speech Pathologist at Childrens. So Meredith, let's take kind of the same approach here and talk about sort of the milestones that a parent can expect to see over the first couple years with language.

Meredith Street, MS, CCC-SLP: Well, you're looking at a couple years, which is a lot of milestones. So what we're looking at as kind of littles, what we're looking at for infants into that first year, we're looking at are they babbling? What kind of babbling are they doing? Are, do we see it as they're only saying, dad, dad, dad, dad, da. Or are they having what we call like a variated babble? So we see lots of different sounds, syllables. Um, we also look at how they are responding. So if you have, if you're talking to your baby and how they respond to you, um, oftentimes we hear from our audiologist friends that, oh, my baby's not turning to their name. Well, as my audiology friends would probably like everybody to know, is that typically that doesn't happen in the first couple months.

They're just turning, learning to turn to sounds. They're learning to like just kind of in investigate and learn about their environment. So in that first couple months, we're really just seeing like, are you exploring your world? Are you trying to make sounds, um, laughing, things like that. As we get a little bit into kind of seven to like nine months, we're looking at some children, you start using some words or what we call word approximations. So words that sound close to words, but maybe not quite accurate yet. Um, as they get a little bit older, older, they will, um, kind of get a little bit more accurate with their speech sounds. Um, closer to one, we start hearing more words. Um, as we get into like one year, 18 months, we want to hear lots more words.

And then as we approach their second birthday, that's when we really want to see closer to like 50 words and a starting of having two word phrases. A lot of those phrases include like parents' names, um, names of their animals in the house, um, addressing themselves, turning to their name, things like that.

Host: Does development vary between boys and girls or, or just be from one kid to another?

Meredith Street, MS, CCC-SLP: There is research that shows that, um, actually most of our assessments that we, um, access kind of different, that kind of separate the boys' development of the girls' development. So that is something that we look at. But again, they kind of more range by just baby to baby too.

Host: Okay. So I guess as long as your child is sort of in that general range for those milestones, then they're in pretty good shape.

Meredith Street, MS, CCC-SLP: Yes. We don't have like a hard, fast, like at five months they need to be doing this. At seven months they'd be doing this. It's more of like a range, like in within this timeline we'd like to see this. Um, it's often what we like to educate parents on, babies are a lot of like what you put in, you get out. Right. So language acquisition comes from what they're expect exposure to and their experiences in, in their environment.

Host: And that kinda leads me into the next question I had, which was about interaction. How important is interaction between a parent and a child in terms of language development?

Meredith Street, MS, CCC-SLP: Pretty, I mean, pretty significant. Yeah. So what we see is that, um, throughout your day, it's hard cause babies don't talk back. So, uh, at least not yet. So just talking about your day, putting a lot of words, um, describing things, using words for a variety of pragmatic functions. So you're talking with them, you're labeling pictures, you're looking at a lot of different things, just kind of talking about what you're doing, cause they're also probably doing it with you. So you're just kind of talking about your world. Um, and in that we see that children acquire the language that they're exposed to.

Host: So if you're going through your day and you point out comb or brush or toothbrush or food or whatever, they hear that and see that and they begin to understand and develop that vocabulary themselves.

Meredith Street, MS, CCC-SLP: Right. And what we see is oftentimes they learn to understand the word before they use the word. So we have what's the receptive and expressive language modalities. And what we see is that they'll start identifying like, this is the brush or this, these are my shoes before they might say, shoe. So we often see that too.

Host: So I guess in a situation like that, you, the baby understands when the parent says this word to them, but they may not necessarily be ready to say it back quite yet.

Meredith Street, MS, CCC-SLP: Right. So we just want to, as much as you're just like when you practice something over and over, the better you get at it. So the more the baby hears all of these words, all of looking at pictures, those interactions with family. So just talking, having conversations is a really important part of just their overall language acquisition.

Host: And I know there can be problems from time to time with language development. Is there a sort of an indication that parents can look out for that their child might be having a problem?

Meredith Street, MS, CCC-SLP: Yeah, so what we look for is kind of in those kind of general milestones, so closer to a year um, to 18 months. We're looking at, um, are, how are they using words? What kind of words are they using? How many words are they using? Um, and then closer to two, we're looking at, um, how many words again. Are we putting two phrase, two word phrases together? Um, younger age we're look kind of looking at some of that babbling, some of those like pre indicators for language. Um, so when parents have a concern, we often ask like, that you speak to your pediatrician, that's kind of your first route.

Um, if you have further concerns, definitely like consult speech, language pathologist, cause whether or not your child's delayed, we'll be able to tell you a little bit more and sometimes just give you education of like, here's what to look for in the next six months. Because as we know, babies don't come with handbooks. So it's sometimes just nice to know that like, hey, in the next six months, these are what to expect, and here's some things to work on.

Host: Always good to, uh, reference whatever you can find, uh, right. Any, any kind of, uh, literature that's out there and, and, and keep your pediatrician involved as well. Very good advice there on both feeding and language development.

Uh, I want to kind of bring both of you in now and talk about some of the other common questions you have. Uh, maybe picky eating. Uh, is, is that, is that one that either of you could talk about? Is, is that comes up pretty often?

Meredith Street, MS, CCC-SLP: Yeah,

Emily Swindle, MS, CCC-SLP: 100%.

Meredith Street, MS, CCC-SLP: Yeah. We see it a often both in inpatient and outpatient. So, um, I think we, we see picky eaters starting at, even what Emily said, said it was even like aversive to bottles. So we see children that are already showing some signs of oral aversions, and that's something we want took at all the way into teenagers that have aversions to different foods, different textures, um, trying different foods. Um, sometimes that can be self restrictive and sometimes, like Emily mentioned, it could be sensory based or oral motor based.

Host: Is, go ahead.

Emily Swindle, MS, CCC-SLP: I was just going to say that, uh, you know, as soon as you see anything that concerns you, it's always good to have early intervention for that. So just because a baby is having bottle aversion doesn't necessarily mean that later on they're going to have challenges with solids and things like that. But it is good to kind of target that early so that we don't grow into some more problems.

Host: With the picky eating specifically, is it, is it a good idea to kind of keep trying certain foods that maybe they've been averse to, just to kind of see if they warm up to it, maybe.

Emily Swindle, MS, CCC-SLP: Definitely, yeah.

Meredith Street, MS, CCC-SLP: We see oftentimes that parents say like, try it, try it, try it. Well, sometimes it just means to be exposed to it, putting it on their plate, letting them touch it, letting them feel it, letting ex kind of get exposed to the smells, because sometimes smells can be big or small, depending on your person. So, um, all of those things can be their objective. Person to person. Um, so I think that just exposing them to foods, exposing them to cooking with you, um, can really help with some of that aversiveness to things that look scary, even though they might be really yummy.

Emily Swindle, MS, CCC-SLP: They need a, a lot of times they need several interactions with the food before they, you know, quote master, that food. So just because they give you a weird face once when you give them pea baby food or you know, soft broccoli. Don't just cut that off because they don't like it. You know, kind of keep introducing and I would say, um, kind of putting, you know, two preferred foods on their plate and one non-preferred food. Just so that they make sure they have control over some things that they like, but also, like she said, being exposed to some of those non-preferred foods.

Host: Giving them an opportunity to kind of maybe make their way into those other ones a little bit. How about pacifier usage? Y'all hear about that a lot.

Meredith Street, MS, CCC-SLP: Often.

Emily Swindle, MS, CCC-SLP: I feel like parents ask a lot about what pacifier we recommend, and I don't really have a passi recommend. I don't. I just kind of feel like pacifiers are good for oral motor simulation, so whatever pacifier your child likes, go for it. And I don't necessarily see a ton of correlation between they use this pacifier so I must use this bottle. Cause they're kind of different. Um, the pacifier is just kind of a non-nutritive suck, whereas the bottle, they're having to kind of compress and pull and completely get that out to swallow. Um, so some babies are picky about pacifiers, but I don't feel like speech therapists are like, well you must use this pacifier.

Meredith Street, MS, CCC-SLP: Yeah. I think most of the time parents ask us about like, can my child use it? And oftentimes it's just, like Emily said, it's for non-nutritive suck for calming. So that can teach them kind of early, um, kinda self sooth. It also, for some parents, it can be calming for them too. But we kind of look at more of like later use of pacifiers is what I often see is, so we have, um, children that are approaching their second birthday mm-hmm. And they're still using a pacifier. At that point, they don't really often need that oral motor, um, component. So they're not needing to practice that non-nutritive suck. What we want to see, um, is that they're learning to self sooth in other ways, um, or they're not talking around it. So it can have huge implications if a child is using a pacifier and talking around it. Cause it's like talking with a stick in your mouth. Um, you learn then difficulties of, um, kind of oral motor planning for speech, not necessarily for feeding.

Host: So what if you're approaching two? And the child still just desperately wants that pacifier. You're having a hard time getting them off of it. Uh, any strategies for that?

Emily Swindle, MS, CCC-SLP: There's a very, I mean, there are tons of things out there for parents to like try. There are, um, supplies that you can buy that kind of wean them off a pacifier. Sometimes we see that, that it doesn't matter. Um, but sometimes it's a behavior modification. So using a reward chart, um, sometimes people go cold turkey. It really kind of depends and you, most parents know their baby best, so they might know which behavior strategy works best. Um, but also talking, talking to either early interventions, speech therapists, speech therapists, or doctors as well.

Host: All right. Well this has been a very comprehensive look at, uh, feeding and language and development and some of the things that y'all see. I really appreciate your time. Uh, once again, Meredith Street and Emily Swindle. Thanks so much.

Emily Swindle, MS, CCC-SLP: Thank you for having us.

Meredith Street, MS, CCC-SLP: Thank you. Yeah.

Host: Thanks for listening to Inside Pediatrics. You can find more podcasts like this one at children's al.org/inside pediatrics.