Mouth Breathing Is a Red Flag Parents Shouldn’t Ignore

Introduction to the podcast and guest 0:00

If a kiddo is mouth breathing, their tongue is not getting to the roof of the mouth. And when that tongue doesn't hit the roof of the mouth, that's not, that's our vagus nerve, right? That's that fight flight freeze. And so as soon as that triggers, then we become an even bigger open mouth breather. And so we might see a kid that they might drool, they might not drool, but if they're starting with open mouth breathing, their nervous system and their neural inflammation, it's gonna skyrocket. I always say we can't, you can supplement and medicate.

We can do that all day long. We are throwing money in a paper shredder if they are mouth breathing. Because mouth breathing is going, if we've got that tongue up and we've got them into a rest and digest state, boom, the dominoes hit, their sleep improves. Welcome to Demystifying Pans and Pandas, the podcast where we uncover the mysteries, breakthroughs and hope behind these life altering conditions. I'm Dr. Nancy O'Hara, a board certified pediatrician, educator and advocate with over three decades of experience.

helping children and families navigate the challenges of neurodevelopmental and neuropsychiatric conditions, especially PANS and PANDAS. These disorders can feel overwhelming, but here we'll break down the science, explore transformative treatments, and share stories of resilience and recovery. If you've ever wondered what's possible for your child or how to find answers, this is the place to start. Let's dive in. Hi, everybody. It's Dr. Nancy O'Hara, and welcome back to Demystifying Pan's Pandas.

And I'm really excited to welcome our guest today, Brie Kersick, who is an amazing occupational therapist in North Carolina. And I have learned so much about the role of sleep and airway and feeding in Pans and Pandas. And I really wanted Bree to come on and talk about that today. Bree earned her Master's of Science in Occupational Therapy from Belmont University in Nashville. And she's had over 19 years of clinical experience as an occupational therapist with advanced training in infant, toddler, child feeding, pediatric, pelvic floor, sensory motor development, and wellness related to nutrition, healthy sleeping habits.

She's the founder and lead clinician of Flourish Carolina. a pediatric private practice in Charlotte where she provides integrative and whole child care to children and families. And she's a national lecturer for MAPS, TACA, and deeply committed to interdisciplinary education community outreach. She served as adjunct faculty and continues to lecture colleges, universities across the country, contributing to the education development of future occupational therapists. Brie, it is so wonderful to have you here.

And I've learned so much from you and about how what you do affects the kids I take care of and what I do.

Why airway, feeding, and sleep matter 3:00

So thanks for being here. Thank you for having me. It's an honor. Well, I really, you know, as I said, you specialize in airway feeding and sleep. So why are those systems so critical to kids with pans and pandas? And why are they often looked even by me? I overlooked them 10 years ago. Yeah. Well, I mean, 10 years ago, we weren't talking about it. You know, it was just, we assumed kids, they just eat and they just sleep and they just poop. And it wasn't something, you know, in OT school, we didn't investigate this.

We had a semester of feeding therapy and it was like, there you go. You know, you're out into the OT world and figure it out. And I really hit a point where I was like, You know, I had a college professor say to me, and God love her, she's been the driving force in the back of my mind, say, you know, Bre, I just really worry you can't see the forest for the trees. And I'm like, but these small details that these kids are without verbal skill, they're not telling us, they're showing us. These small little clues make the forest, they make the big picture.

And I remember that moment, you know, sitting in grad school saying, OK, I'm going to get through this program. It served me well. But there is so much more to this and really just kind of went down an integrative path to say these kids aren't eating, sleeping and pooping. And 19 years ago, coming out of school, I was doing shoe tying and digging beads out of putty in your traditional OT. And it was like, wait a minute, I just kept seeing kids get sicker and sicker and these layers and layers of uncovering.

And I just started kind of digging backwards and really got into feeding, knowing, all right, it's such a source of contention with families, right? Picky eating. I hate the term. I don't believe in it. There's always a root cause to it. And it's like it's rarely just picky eating. There's usually so much more that goes into it. And so when kiddos are getting this sensory based path of you know, feeding without looking at how is their tongue moving? How are they breathing? How are they sleeping?

Are they pooping? How the heck are we doing feeding therapy, if no one's investigating their entire airway, what is happening with their bowel habits, we're just over here like, Johnny, I just really need you to eat your fruits and vegetables. And so looking, I feel like you can't look at one without the other. It is a head to toe approach. And when a kiddo is not doing one well, they're likely not doing any of those categories well at all. And I so appreciate the integrative approach, the functional medicine, the root cause approach.

It's all what we talk about on this podcast, and as you know, in my practice. And it's so amazing. We don't have as many people like you around me. There are some. But it's so amazing to be able to talk to an occupational therapist who's not just giving the M&M. to get the behavior that you want. And the other thing that comes to mind as you speak is all the ways that what you do and what you're talking about affects the vagal nerve and is affected by the vagal nerve. And so much in our kids with Pan's Pandas, it's fight, flight, freeze behavior.

And what I've come to learn is how much what you do really affects that and how these kids can get better. I love to say, food refusal, sleep refusal, poop refusal, whatever it is, it's not defiance, it's not behavior, it's protection. Their body is so inflamed, they are just trying to make it through the next meal. They are just trying to make it through the next night of sleep. They're not giving us a hard time, they're having a hard time. And their body, speaking of the vagus nerve, there's These kiddos are living in fight, flight, freeze.

They're just, they are at a level where they can't come out of it. And so, you know, the packaging of the box or the container of the food that changed, or that one soft, smushy blueberry versus their hard, firm, crunchy blueberries that they like, that's enough to send their nervous system. It's already at its peak and it can't come down and regulate. And now, okay, I just ate the yucky blueberry, blueberries are gone. They're done. And it's like, dang it, we just, we lost a food. Yeah. Yeah. So important.

And like you said, these feeding challenges are not behavioral. No. So explain a little bit more how the neuroinflammation, the nervous system threat responses, how that impacts the eating, the appetite, the oral motor skills. Yeah. So it's interesting because I started working with kiddos with pans and pandas years ago, seven years ago. And it was like, my first couple of cases, was oh you know they had this sudden onset of picky eating and I'm like okay wait so they weren't the toddler that at two or three just stopped eating it was like no they're five and they woke up and they stopped eating and I'm like okay wait a minute so it really took me down a deep dive of like this is so fascinating and you know there's so many more layers to this and you know, really digging into it.

And as I've, you know, been practicing more and seeing kids, kids are flying in from all over the country to see me. I'm getting, you know, emails and phone calls. I heard you at talk or heard you at maps, you know, help, help my child or help these, you know, patients of mine. And I'm finding that these kiddos, the flags from an airway standpoint have been there. And, you know, as I go through history and intake, it's like, okay, did they have breast or bottle feeding dysfunction? Oh yeah, you know, they would never take a bottle.

They breastfed for the year and everything was fine. And then, you know, they went on to solids and we did baby led weaning and then they hit two and they just, you know, they were up a picky two year old. And I'm like, okay, another red flag. And it's like, it's just the story kind of keeps progressing.

How neuroinflammation affects eating and breathing 9:00

And so when I'm evaluating a kiddo, I'm looking back at their whole history. I know it's sometimes hard for parents, especially when we're in the stress point of a new onset. Maybe they don't even have the diagnosis yet, but I'm going all the way back to the beginning to say, let's problem solve structurally. Let's see, do we have red flags that maybe they were getting the job done, breast and bottle feeding, but they weren't doing it with good skill. And that tells me a lot of what's happening with the tongue.

Does the tongue know how to move correctly? Because that's a cranial nerve. So if we've got neuroinflammation in the brain and we've got feeding challenges, there's something not mixing together. So yes, we can have the sudden onset of food refusal and sleep refusal and things, but I'm going all the way back to the intake of day one. What did their sleep look like as an infant? What was their breathing pattern like? Oh, they snore. That's a Smith family gene. I'm like, common, not normal. And so we're looking at if that tongue does not have good mobility or Eating and drinking that likely tells me that it's not suctioned up into the roof of the mouth, which is our vagus nerve There is our rest and digest well that then directly pays into our body getting into parasympathetic and Sympathetic state which is that up and down of our nervous system.

Well, that's going to impact our sleep And then once our sleep is impacted, that impacts our hormones, that impacts our digestion, our vitamin and mineral absorption, you know, then playing into the leuka. It's just the dominoes just keep falling. So it's like we have to look all the way back. And I always say, I start with an oral exam. I'll have kiddos that often they can walk in my office. I take one look at their facial structure and I'm like, all right, I know where we're going. It's already that obvious.

Yeah. Yeah. And, you know, for me, I always focus on the three-pronged approach, you know, antimicrobials, immune system, you know, support, symptom support. But I never previously, until really the last five years or so, focused on things like oral posture and mouth breathing and the tongue function you're talking about. And those are so important. And like you said, that kid that walks in with their mouth open, I may have previously thought, well, their sinuses are all blocked up or they look a little bit like they may have a low IQ.

None of that may be true. It has more to do with their oral posture, their mouth breathing. So talk about those airway mechanics a little bit more and how it influences these kids. I say that mouth breathing is a danger sign for anyone. Anyone, you don't have to have pans and pandas, mouth breathing is a danger sign. And it's normalized, right? I was just on a field trip yesterday with my fourth grader and I just, I couldn't shut it off. I was like, Bri, stop. I mean, I was analyzing and evaluating all of these kids, just their oral posture.

And I'm like, no wonder this little guy, you know, he's just so slumped over. He can't even hold his body upright. because everything it's like he has puppet string you know marionette strings just pulling down on his entire facial structure and so if a kiddo is mouth breathing their tongue is not getting to the roof of the mouth and when that tongue doesn't hit the roof of the mouth that's not that that's our vegas nerve right that's that fight flight freeze and so as soon as that triggers then we become an even bigger open mouth breather And so we might see a kid that they might drool, they might not drool, but if they're starting with open mouth breathing, their nervous system and their neural inflammation, it's going to skyrocket.

I always say we can't, you can supplement and medicate. We can do that all day long. We are throwing money in a paper shredder if they are mouth breathing. Because mouth breathing is going, if we've got that tongue up and we've got them into a rest and digest state, boom, the dominoes hit. Their sleep improves. Their gut can do its job. So kids who, you know, if they're mouth breathing and you know, parents will say like, no, they're getting 10 hours of sleep or 12 hours of sleep. No, but how restful is their sleep?

We know that mouth breathers, it is a proven fact that their IQ scores are lower. We are depriving them. When that oxygen deprivation is happening, That's absolutely impacted. I know, we know you don't sleep well for a night. You wake up, you're like, oh my gosh, I'm foggy headed. I'm exhausted. And now we've got these kiddos that have all of this other inflammation in their body. The mouth breathing is like, and I always say it's the red carpet into in head-to-toe inflammation, because if we're not nasal breathing, we don't filter out, we blow our nose, right?

We blow out germs, dust, bacteria. We're mouth breathing, all of that in the air gets a straight red carpet invite, boom, hits the tonsils, there's our lymphatic system, messes with the gut, you know, it just, it impacts all of it. Right. And so much to unpack there. I mean, first of all, it's not just Pan's Pandas. When you talk about snoring and restless sleep, you know, I've had kids come to me for assessment for stimulant medications for ADHD. And if you do a history that involves, you know, sleep and the mouth breathing, and you fix the sleep apnea, you remove the tonsils and adenoids, not for strep.

But for obstructive sleep apnea, all of a sudden, the kid has no ADD symptoms. Right. Well, and to that point, you know, I'll get kiddos that the parents have done that. They've done the tonsils and adenoids, and no one looked at the tongue. No one looked at the knee. Okay. You know, I always say airway dentistry is huge. I work very closely with a phenomenal airway dentist who orthodontist who's really looking at opening the entire airway, you know, 20 years ago, we just took tea out of a kid because we said, oh yeah, they don't fit your jaws too small.

You're too narrow instead of opening them up. And we've got parents, I see parents all the time, highly medicated on, you know, ADHD meds. A lot of them, you know, they'll be on meds for mental health issues or, oh, they have this or they have that. And I'm like, the dark circles under their eyes and no, no, they sleep 12 hours. I have to wake them in the morning. They are just dead asleep. I'm like, their body is not getting quality. I don't care about the quantity of sleep they're getting. I want to know their quality.

And it's hard because as kids, you know, if they're not interrupting your sleep as the parent, you don't know. You're like, no, they're in their room. They're fine. Never realizing how disruptive their sleep can be from the start. Right. And we're not talking about expensive stuff. I mean, a parent can set up their iPhone and do a video of their child at night to show that they're a very restless sleeper. Every time they get into that deep REM restful rejuvenant sleep, they wake up because of the obstructive sleep apnea or the posture of their tongue or whatever.

And You know, it's not just about the cranial nerve inflammation, it's also about that the immune system rejuvenates during sleep. And if you're not getting to that deep REM sleep, your immune system is not going to recover and refresh and restore. I see the parents in those cases, their body is just, they're training for a marathon and they run the marathon every night. They're not getting into a place of, their body can't rest if they're not breathing. As much as we don't love Apple watches and whoops and all the devices for the EMF exposure, that is a cheap way for parents, but most people have access within family.

I'm like, every once in a while I'll get a parent that's like, no, they don't have a sleep issue. I'm like, but I need you to prove it, we have to prove it. And, you know, I always like to say, okay, you took a family vacation, you shared a hotel room, what happened? Oh, they tossed, they turned, they snored, they were kicking the siblings and they're awful. And I'm like, all right, go share a bed with them for a night or, you know, if you're happening, holidays are great. I love, I love the post-holiday visits because people come up and they're like, you were right, they don't sleep.

Mouth breathing, tongue posture, and sleep quality 17:00

And I'm like, I know, I told you. but you know throw an apple watch on now the detection and like I said yeah you're good some emf exposure and the negatives for it but the positives it can be free data if you have access to that watch and it's amazing I tell parents I'm like I need a screenshot I need a screenshot and I want you to do it over two weeks and just do like every other night don't just do tonight don't do two nights in a row let's bounce around because you know maybe they have sports maybe they had a busier day a less busy day you know I really want to see over a couple of weeks, what is the quality of their sleep look like?

And that often is enough of proof. It takes parents usually two nights and they're like, oh my God. You were right. I'm like, I know, but it goes, I think in my opinion, sleep, picky eating and feeding challenges, it's obvious. It's all day long, parents are so frustrated. But sleep issues go so undetected because we just, it's kind of like bowel issues. Once we stop wiping our kiddo's bum, We don't know what their poops look like unless they tell us or we're actively investigating. So the sleep piece is crucial and so overlooked all the time.

And talk a little bit about then, so you find this, what are the things you talk to families about doing or what are the things you do to try to correct the issues? Yeah. So it's hard because a lot of times I look like, you know, this magician, I just solved all of these problems in a 75 minute evaluation. And I'm like, okay, but buckle up with me because we've got months and years sometimes of undoing. So sometimes parents get very excited and we have answers and we have a plan. And I tell them, now you got to buckle up with me.

This can be, we're going to do it. you know, the least expensive, the most efficient. I am not a therapist. My wait list is way too long. I don't pull kids in, you know, for weekly therapy and just tap, lick, taste, food, sensory based. No, we're getting to the root. But from a sleep standpoint, if I detect, you know, sleep disorder, breathing or apnea is actually show up and parents are like, I want to further, you know, I want to sleep. I want to actual sleep study. Great. They can go to sleep medicine.

They can go to their PCP. We've got, you know, providers across the country that will ship kits out of state lines, and you can do a home study. But I always say, if you have enough check marks that we know you're restless, you're grinding, you're sweating, you are actually snoring, you're drooling on the pillow, nightly nosebleeds, if we've got all these signs, you can spend the money to get, you know, quote confirmation, or we can assume that you're checking enough boxes of sleep disorder breathing.

So I'm right away looking then at the oral cavity. Why isn't the child sleeping? You know, do they know how to breathe through their nose? If they've been a chronic mouth breather, they may not even know in the daytime if they're watching a little show or I always say riding in the car if they're just in the back, tongue down. First, we're going to work on some training because it's pretty amazing for kiddos that can follow commands and parents that can instruct them at home. I might teach them to make a bubble, get that tongue, tickle the roof of your mouth, close your teeth, close your lips, And just breathe, just breathe like you're smelling the flowers.

It doesn't have to be this big obnoxious, but you know, let's see, do they even know how to nasal breathe? If not, they're coming in person therapy, and we're going to teach them that. Second part is breathing is one aspect, but so is tongue mobility. If they can't get that tongue moving, the amount of children that come into my office and I say, I want you to tickle your very back tooth with the tip of your tongue. They can't do it. They can't move that tongue back there. So if they can't reach their back molar, they sure are not chewing meat and fibrous vegetables that need to be chewed back there.

So no wonder they're eating that, you know, I call it the tan soft diet, your waffles, your pancakes, your quesadillas, your yogurt, it's carbs and dairy because that's all that they can eat using the tea here. So I'm looking big picture of we've got the sleep study or we've got sleep disorder breathing checked off. I'm checking nasal breathing. I'm checking tongue mobility. And if they're of age, so in Charlotte, we've got a provider that three and a half can do a full comprehensive airway scan.

And what that's going to look at is, what does their sinus cavity look like? What do their adenomes look like? What does the growth and development of their upper jaw look like? Well, the upper jaw, I always say, is our garage. And if our tongue is a suburban and it fits our face, but our garage is fitting a little Honda Accord, that tongue has nowhere to go. So if we can get them scanned and look at what is their airway and the dimensions of it, you know, predictable future growth, they might benefit from pallet expansion.

And there's lots of, you know, forms and lots of ways, but we got to get their garage into a two car garage. We got to get that tongue so it can fit up there because if it's constantly wiggling and it can't fit, why is it going to keep going up there? So after we've got the sleep study, we're going to probably get an airway exam. After we've got the airway exam and have a path there, I need to teach that tongue. It's a muscle just like any other muscle of our body. So I need to teach it where it's where it lives.

It lives in the garage. And, you know, we're doing that obviously with fun. We're not just taking a toddler or a big kid and just, you know, it's fun. It's silly. We make funny faces. We use food to do it. But I won't touch a kiddo with any sensory based You know, feeding therapy, that is the absolute end. I'm looking at breathing airway first. So usually those steps for parents, sleep study, airway orthodontist, looking big picture, getting that tongue if they need ENT and they need surgery, you know, Every case is different.

A lot of, you know, mom's groups and things. Oh, we did this and we removed tonsils and adenoids. I'm like, check the tongue. Within a family, a sibling set are necessarily the same. So that's we're hitting that hard. And you know, when kiddos, if they go into expansion, and we're getting some orthodontic work done, we have to be mindful of our pants and this kiddos because That's messing with those cranial nerves. That can send nervous systems in and of itself. So there's a lot of factors that we're looking at on what is right for this child right now and what is going to be our best bet long term to get us our eventual goals of nasal breathing, quality sleep, et cetera.

Right. And again, so much to unpack there. I mean, I love analogies and that garage analogy is great. I never heard that before. And so many of our kids, you can just see it mentally that that garage only has room for that mini. Yep. You know, and you really have to work on that craniosacraly, orthodontically, OT, all of that. And then the other thing I always remind practitioners about, whether you're doing a telehealth visit or an in-person visit, look at that tongue. Play games with the kid. Ask their kid to put their tongue up to their nose and look at the sides.

There's so much you can learn. I mean, I learned it first from a acupuncturist. how much you can learn from the tongue, you know, the scalloping with adrenal stress, the coloring, you know, when it's white with yeast overgrowth, the strawberry tongue with pandas, but so much, you know, the tongue ties, you know, not just the tongue, but all the other ties with MTHFR and other things. I mean, there are so many things you can learn. You know, you should be looking at that. And even as a physician that feels, is hearing this and they're like, oh my gosh, I need a course in this, we'll get you trained.

But ask the child, mom's got snacks in her bag at your appointment, ask the child to eat, just watch them eat. And you don't have to be a feeding professional to watch a kid eat. If that's the kid that you're like, okay, what the heck is happening here? We've got to address that. We've got, if they're the messy eater, if they're, you know, just smacking their lips all around. These are basic things that we, you know, as outsiders look at a restaurant and judge like, oh my gosh, I can't, so, you know, they're making a mess or whatever it is.

Those are the basic obvious things. And yes, there are kids that don't have as obvious of symptoms, but you know, us, just like you said, ask them to perform some things. I can make a quick little checklist for providers to say, look at these five or 10 things. And if you see this, get them to an OT that's going to look you know, comprehensively and do the big picture evaluation on them because that is imperative for their healing. Imperative. Yeah, absolutely. And, okay, we've talked about sleep.

Let's talk a little bit more about food and eating. You know, there are some kids with Pan's Pandas that have a fear of choking or vomiting or contamination. There are others that present more with gagging and pocketing food and the fatigue with chewing and all of that.

Evaluating sleep, airway, and oral function 26:00

Talk a little bit more about those patterns. So I always say, assume function or dysfunction before behavior, always. We know that those are your baseline symptoms, right? My own son woke with his journey with pandas and one day I was making dinner and he said, I don't eat broccoli cooked longer than 15 minutes. And I nearly dropped the panini. I was like, there it is. There's his check mark right there, right in front of my eyes. And I was like, what do you mean you don't eat broccoli cooked longer than 15 minutes?

He's like, I don't. It turns brown or whatever he had said. And I look at these kiddos and I say, this is neurological overload. Their body is having to pick what is survival. And they, the brain is making up to parents and providers and care teams these arbitrary rules like I don't eat broccoli cooked longer than 15 minutes or I don't eat purple foods. I don't eat meat now all of a sudden. So we first have to look for these kiddos to say, okay, if we have the sudden onset of gagging, what is going on neurologically and within their nervous system, because this is a non-pans-pans kiddo or any situation, you have a gagging episode, you had a trauma related to that food.

So you're then gonna look at, let's say you ate too big of a bite of a bagel and it didn't go down easily. you're now going to look at faggles, you might even look at English muffins, you might even look at a pizza crust, the brain starts playing tricks, and it will say, Oh, that's going to happen again. So not only do we have that side of maybe there was a trauma, or there was a negative experience, you know, grandma said you're not getting up from Thanksgiving table till you clear your plate. And it's like, You know that created a stress point there so we have to look at traumas, but we also have to look first before we look behaviorally we have to look at oral function so is if there's a gagging episode and a sudden onset of you know food refusal and picky eating in pants band as kiddos.

Okay, we've got to look at that. But did they actually have some red flags from a feeding standpoint prior that were just never picked up on and the majority of kids that I see they had that going on prior it exacerbated and now the symptoms around the eating, you know really rose to the surface and because we're getting refusal and we're getting avoidance. It's like Yeah, no, they never had a feeding problem. And now they do. Obviously, that's even more of a marker of like, okay, we've got to get you to an integrative specialist, we got to see if this is, you know, pans pan is going on.

But overall, it tells me if we're gagging, if we're refusing, if we're avoiding, there is something nervous system and neurological happening where the brain and the mouth they're not working together. And was it a minor episode that triggered something? Is it a large, is it neuroinflammation? What's happening in between? But first rule out, can they do it? And then if they physically and structurally, there's no tongue tie, they have the mobility, then we got to look at, is this trauma? Is this inflammation?

Is it OCD? What's happening that is causing these rules and stipulations, if you will, around It's neurological overload. Right. And I think it's so important to ferret out all those different things. Yeah. You know, the trauma piece. I mean, you know, in my own personal history, I had to do a Heimlich on the side, on a counter side, choking on a vitamin C pill. Yeah. So I still, to this day, you know, I have that little twinge of fear every time I go to swallow my pills, you know. And so you got to know that in the child's history, the OCD part of it.

I mean, sometimes the only wanting to eat this is part of their OCD. It's a color thing, not a texture thing or whatever. And then, you know, to all the other things we're talking about, sometimes it's a mouth thing. And so knowing those, each one of those can be important pieces, but knowing which one or ones it is really helps the approach and the management. And that's why we have to look at all of the pieces and the big picture and know as a therapist to ask the right questions because we're so often as OTs trained to come at the sensory aspect of it.

Oh, it's sensory. And then if it's not a sensory issue, the way the food feels, it's a behavioral issue. And I'm like, No, no, we're missing these little, that's where I'm like, forest trees, she said it to me. No, these are the little clues that what's been going on each little tree to create the whole forest that makes this big picture. We've got to be able to look at that and decipher that because this is where traditional feeding therapy, I get kids, we've been in OT for three years. Oh, we've been in OT for, and I'm like, what have you been doing?

What a parent can't say to me what they've been doing. I'm like, you've been dropping them off or paying this copay like, no, no, no, you're involved. You're in these sessions. And if you can't be in the nanny or the au pair, whoever's here, they're videotaping, they're taking notes like this is a family. involvement in looking big picture at these kiddos. And we've got to go back, I'm going to jog parents memories to places that they're like, free, I don't remember. But sometimes the kids like up and like, well, on data date, this happened.

And I'm like, there it is, there is and that's then, you know, that takes us down this path of treatment. It's like, in any given day in clinic, I always say I'm eight different versions of Brie because I can't look at any two kids just like you. You're not taking any two kids on their intake form and treating them the same. You're digging to ask more questions and say, there it is. That is that important piece of information that's gonna guide us to this treatment path. Right. And I think something else you said is so important.

You know, this isn't one 45 minute or hour session once a week that's going to solve all these problems. This is a whole child approach, but also a whole family approach that unless these things are reinforced and in some way, in a fun way, theorized, I don't even know if that's a word, but whatever, at home, you know, it's not gonna work. Right. Well, and, you know, specifically in Pan's Pandas cases, if you've got, you know, one kiddo that is creating unintentional stressors over eating and the family meals, it is impacting.

I live it. I've lived it, you know, in my own four walls of, it's a family issue. It's a friendship issue. It's the big picture. And it can create feeding issues or a kid who doesn't sleep. These basic ADL, these basic activities that we all engage in, eating, sleeping, and pooping, when they're not happening, and it's disrupting the entire family, the entire family. Yeah. So it does, it has to be improved. Yeah, absolutely. And I heard you say these words a little bit earlier, and I want you to go into the tongue-to-toes approach.

Yeah. Just talk about, I think you're saying it, but just explain that a little bit more. Yeah, so it's kind of my evaluation kind of pathway when I'm looking at a kid. Obviously, it's what I can see on the outside and what's so visible from a mouth standpoint, but I really start big picture of them. So I'm looking in that multiprong approach of, okay what's happening in their balance and coordination we have these kids that they're in ot they're in pt they're in speech and it's like they're each therapist is doing their own thing but nobody's coming back to put those pieces together to say well no wonder they have balance and coordination issues it's because they're so severely restricted in their tongue with a tongue tie that their entire fascial system head to toe is pulling them knock need is pulling their pelvis into a tilt.

Well, that's impacting their digestion and ability to poop and eliminate all the poop. So looking at a kid, you know, from the top of their head all the way to the bottom of their feet, what are their primitive reflexes look like? You know, okay, well, we're just going and doing just primitive reflex therapy or just craniosacral therapy. Okay, we're not looking at the entire picture. And sometimes kiddos I find are getting services with amazing providers, but they're dead ends. They're not getting better in that.

It's because go back up the chain of the body, looking head, toes, tongue, toes, and see where is the root? What is stopping us? If we are in PT for body work, well what's going on in the mouth you know and then vice versa back down the other way why are we in feeding therapy if we are having pelvic floor issues or constipation issues and their body their interoception and their awareness of eliminating and emptying the bowels

Feeding challenges, gagging, and food refusal 35:00

if that's not happening you're making any progress in feeding therapy so it goes you've got to be able to look literally head to toe at every single component and then be able to put it all together and say, okay, where do we start first to make the biggest impact? And that's what I find missing as I teach and, you know, educate other professionals. It's like phenomenal mindset, phenomenal intention on addressing this one issue. But then we just see sold or whack a mold the others. And it's like, okay, wait, we got to step back and look at the big whack a mold pond and say, okay, we're going to get all these fires out.

all at the same time or whichever one is creating the biggest wave. Right. And going back to that fight, flight, freeze, again, it's so important to focus on all of this fascial and everything you're talking about. And I can just hear the parents that are listening or watching saying, oh my God, I thought I just had to find a doctor or a naturopath or somebody to give my kid the right antimicrobial or whatever. Now you're telling me I need to do this whole other area. Talk to families why occupational therapy, feeding therapy, airway focus therapy, whatever should be part of their care team.

Yeah. I always say, you know, I feel like we can't do this without one another. In getting to the true root and getting resolution, getting these kids healed, it takes so much. And it's so, you know, parents that are listening, they're like, I know our bank accounts are drained, our energy, but you know, mom and dad's nervous system is shot as well. It's a whole family issue. But I truly in my heart really am so lucky to have so many good practitioners that value the work that I do because like I said, you know, We've all been a new OT.

We've all been new physicians. We've all been new in our jobs. And I think what keeps people learning and advancing in practice is going to bed at night saying like, man, that didn't work. I did this and it didn't work. We're practicing medicine. We're not experts. We're practicing every day and we've done it for 20 and 30 years. But looking at that big picture and saying, how can we work together? Because like you said, if you're addressing the gut and they're on supplements and meds and prescriptions and they're doing all of this and they're over your mouth breathing and they're not sleeping, we're not going to get them as far as they could get into a state of healing if we had those pieces together.

You know, from a therapy standpoint, I'm really starting to see as I teach, I love when I latch on to that therapist as a student that I'm like, you get it, you're the me, you're looking at the forest, but you're also looking at the trees and you're looking at it together and saying, wait a minute, this doesn't add up. There is more to this. I wanna learn about that other side of, you know, collaboration. I think in depending on the setting as an OT, sometimes we're very respected by physicians and sometimes we're like the, well I don't know I can't figure them out the parents are complaining just get a referral to therapy those therapists will figure them out you know it's like we're we're and sometimes we're the frontline defense in you know the parents are going to the pediatrician or their pcp and saying hey they're exhibiting x y and z help us and physicians like oh you know it's behavioral oh just go to some ot that's what really drew me into this path and you know, working my way into the med map scene of like, this is a physician organization, but I'm like, we belong, we need in work together to get these outcomes.

And we shared kiddos, you know, we have good results, we know that it's a big picture. And I think if we as therapists can help these kiddos function and regulate and live. That's what OT, our job is helping kids live, you know, their daily life. And we can be supportive to parents, then your work is going to work even more. Right. Right. And it's not going to work as well without it either. But I'm just thinking as you're talking, sitting here as a parent, I'm like, my OT doesn't do that. Not everybody can come to you.

How does somebody know the right questions to ask to figure out if their OT gets it the way you do? Right. You know, look, ask them flat out. Like, hey, what's our plan? You know, parents ask OTs. I always say, ask your therapist, sit down with them, have a conversation. It doesn't even have to be with the child. Do, you know, a home program, a parent education visit of saying, What is our end goal? What is our plan? How long do we need to work? I love when a parent looks at me and says, how long do you need from me to work on this?

And I can give them an estimate and say, we're going to do four or five sessions. We're going to do this. And if we're not seeing results here, we're changing directions. I am not taking your time, money, and energy to just bring your child in weekly and spin wheels. I need results. And so when I get the parent, I say, here's your homework. Go home and do these three things. And I get a text message 10 days later, a week later. My gosh, like I just saw X, Y, Z. I'm like, we are on it. We're on the right path.

So I am working on a project to maybe by the time this is published, it will be announced, but working on a project to help therapists look at this big picture mindset and see, okay, we learn all these wonderful things in school and in grad school. We take all of these amazing continuing ed courses. but I've yet to find one that's putting the dots together to look big picture. And so it's coming. It's coming from an OT standpoint. But I think if parents can ask their OTs, you know, it's okay. I think we need to be self-reflective as all medical providers to know, what are we really good at?

Be really good at that. And if we can really sit and look at what our focus area is, I'll pull other OTs in who are really, they might be body workers. They might do primitive reflex work. You know, they might be a bit, don't ask me to do anything vision related. I'm like, I didn't even remember vision stuff in grad school, you know? So parents talk to your therapist and see, you know, if you're not feeling heard, don't throw the baby out with the bathwater. Don't throw OT out as a no-go. It might just be that provider's specialty is in an area that served its purpose then and we just need to get another opinion.

So asking them, hey, you know, what is your specialty? If you're a sensory based feeding therapist, get me in with somebody who can look at the airway, look at the oral motor skills, who can look at the mouth. And then do we need to pull somebody in that's pelvic floor trained? I just so happen to love being a nerd and learning and constantly I'm like looking at all the pieces to it and put it all together. And I'm hoping that OT as an allied health profession is gonna move into that direction because we need to.

We need to be looking bigger picture from a pediatric standpoint with our kids just being sicker. So have conversations, parents. If you're listening, have conversations with your therapist and it's okay to say, can we pull or do we need to pull someone else in that specializes in this area? That does not make that therapist any less than at all. Right. Right. And if they bulk at that, that tells you something too. And I think, yeah. And I think as practitioners, we also have to remember to know what we know, but also know what we don't know.

None of us can know everything. None of us can be a specialist in everything. Right. And being honest about that with ourselves and with our families is really important. Your child really needs chelation, but I'm not the person to do that with you. But if your child has a tick-borne disease, I'm all over it.

Whole-child treatment and family collaboration 43:00

Whatever it may be, the same way with the pelvic floor, the sleep, the eating, whatever it may be, figure out your child and find the people to bring in that can help your child master those things. In this, you know, pediatric population and pans, pandas and autism and in all everything, it is such a team effort and it's okay to, you know, do a therapy or an intervention and pause it if you're being fed, you know, that you're feeling led to another path. That doesn't mean that intervention didn't work or isn't going to work.

It may have just been the wrong time. And I think we as providers, the best providers that get outcomes are ones who listen to the parents. The parents are often coming in with, my kid is doing this, this and this. We'll get parents that come in and they're like, I'm so overwhelmed and I feel like a bad mom. I had no idea they weren't sleeping. I'm like, you're not a sleep professional. You should be asleep too because your nervous system needs regulated. Giving parents homework that's effective.

I need you to go home and track their sleep. I need you to go home Johnny and you and mom are going to have this deal and you don't have to tell sister and you don't have to tell dad but here's the Bristol stool scale and I need you to come home from school every day and say I pooped after math and it looks like number four. great like we've got to start getting data and teaching parents to be the investigators, you know, because they're the ones bringing information back in my hour visits. I'm only seeing what's in front of me.

I need their support outside of it and parents want to figure these things out. They're tired. They're exhausted. They want the support. If we arm them with the tools to be many, I always say like you're turning into a mini little here, you know, I love a parent, they'll, they'll text me and they're like, I'm on a plane and I see all these mouth breathers and I'm like, I know, right? Or it's like, you know, at the family dinner, we're all talking about everybody's bowel movements. I'm like, great, because Everybody poops, you know?

It's teaching parents to lean into their intuition and be the investigator. I'm going to solve it for them. We're going to get results, but we've got to work. We've got to have a big team. Yeah. And I also think it's important, something you said, to know when to do the therapy. For example, a parent will say to me, oh, I did that five years ago and it didn't work. And I will say back, well, your child wasn't prepared at that time. You know, they were still very constipated or they weren't sleeping and it wasn't going to work then.

let's retry it now, or you know what, yes, you did it then, but you did it with this professional who wasn't really as well-trained as who I'm sending you to now, and it may be a totally different experience. So being open to reopening those doors that you may have thought were closed before, I think that's important. mean, you do what that is a physician to write, oh, we've seen so and so, or, you know, we've done all of these things, what are you going to be able to do different? And it's like, you know, I tell everybody, I'm not quarterbacking, I'm not Monday morning quarterbacking, what you know, went on on Sunday's game, like, we are all looking and sometimes it takes just a fresh lens to look at a kiddo and say, Oh, well, this did it did it, you know, do all of these things.

And it looks It's like, well, why didn't my therapist do this last year or the last three years? Well, they were looking with a different lens. And I think if we can just get more therapists specifically, my goal, you know, in my new project is to really get OT's thinking big picture, but you're, you've got to get the little trees. You got to get the little trees and those details to make the forest because so much of our training is forest. And this is what you do. And it's like, no, this little section over here and this little section here, these are all little clues that are going to lead us to that big picture.

Well, Brie, I know so many people are saying right now, oh, I wish I lived in Charlotte. I wish I could go see Brie. But if somebody can or if a practitioner wants to reach out to you first, how do they find you? Yes. So if you're nearby or you want to make a flight in or you want to hop in a car and come on down, I've seen kids literally all over the country travel in and it's, you know, it's been awesome. So My private practice is Flourish Carolina. So on Instagram, you can find us FlourishCarolinaOT.

And then I am launching Bree.ThePedsOT, which is a journey journey to my lifelong dream of just teaching. I love teaching other OTs and, you know, getting them to look big picture. So on Instagram, it's Bree.ThePedsOT. And if you're an OT, you're like, whoa, how did she learn all this? And how is she putting these dots together? That's a way that I'm hoping to really branch out and teach other professionals, not just OTs, but how to look big picture and help support you guys in this path of healing kids.

But I can see that to be so helpful for practitioners, you know, just to learn what we don't know because it's, you know, not only do we not get more than a half an hour of nutrition in medical school, we don't get any OT or anything like that. So, it's great for everybody. we're the allied health team, right? You know we're there to support, but it's like if we, you know, as physicians don't know what our specialties are and what we sometimes just get lumped into like, oh yeah, those OTs, they'll do some sensory work and they'll teach shoe tying or they might get a kid to eat, you know, a new brand of french fries.

There's so much more and within our scope as an OT, like we can do it. It's just, it's a new way of thinking and I'm hoping that the way that medicine is going and the way that our children are just sick, that we can look and heal so many more. You know, the eager beaver parents that as an infant, they bring me their kiddo that's struggling breast and bottle feeding, and they come back at six months because they want to make sure they're doing well on solids. And they come back at 18 months to make sure that their mouth is developing correctly.

Those are the kids that they are getting a lifelong gift from their parents to You know, they're the parents that are looking big picture and they're making sure, you know, we have so there's so much information on the internet. I didn't have that as a new mom 11 years ago. Like it just, it wasn't what it is now, but it's like, those are the parents that are saying, Hey, I just want to make sure we're on a good path because I want to be, I want to be preventative. I want to be proactive instead of being reactive.

So it's the tides are turning. I think it's, we're, we're moving into a good, a good place. I think it's going to be great. Yeah, yeah, I so agree. And with people like you out there teaching us, absolutely will be. Thank you. So any last words of experience, strength or hope you wanna leave our families or practitioners with? I mean, for practitioners, find your crew, find your team. You can't do this alone as a physician trying to carry the weight and the stress of it all.

Finding the right providers and closing advice 50:00

Find a team, create a team. Have people reach out to me and say, Hey, I listened to this or I got your information. Where can I go? I'm interconnected with all sorts of training and other providers across the country that, oh, I have an interest in tongue ties. Great. Take this course. You're going to learn so much about them and how to evaluate them properly. These, especially tongue ties, these are things that we don't want to just be, oh, I took a weekend course and now go ahead and go get your tongue tie released.

No. This is a big picture piece. you know if you're if you're a provider find your team create a team and and train up together really become experts and it doesn't have to be just locally you can have people outside of your city limits you know yeah um and then as parents like lean into your intuition we so often as a as a parent of kiddos with challenges like We so often dismiss them or let other professionals dismiss us and we shut that off. Don't shut that off. Push through. There are providers out there that believe you, that want to help you.

Find us, find me. If I'm not the provider that you need, I'll tell you who to see in the community of a different discipline. So wean into that. Oh, there's so many of us spending day and night and hours and hours trying to heal kids. And we want, you know, we want healing and we want families to exhale and not feel so stressed out. So we're out there. Find us, reach out. We want, we want healing. Yeah, absolutely. And as a parent, like you said, trust your gut, trust your child's gut, check your child's gut, check their poop.

That's not emptying that gut for four days at a time and we're going to trust that? No, no, we're going to get there. We're going to empty that gut and then we're going to trust it for sure. Yeah. Yeah. Well, Brie, so much great information and thank you so much for all your pearls of wisdom, your hard work. I'll so look forward to the course you're planning and all the lectures, you know, at TACA, at MedMaps, wherever. So thanks so much for all you do. And thank you. Thank you for having me and all that you're doing.

All right, we'll see you next time on Demystifying Pan's Pandas. Thanks, everybody. That's it for today's episode of Demystifying Pan's Pandas. I hope you're walking away with insights, tools, and hope to help you and your child on this journey. If you found today's conversation valuable, be sure to subscribe so you never miss an episode. Share this podcast with anyone who might need it. It could be the lifeline they're searching for. And if you have a moment, leaving a review helps us reach even more families who deserve answers.

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