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Ep. 54 – NICU Speech Language Pathology & Occupational Therapy- The safeguards of your breastfeeding journey, with guests Katie Fluharty, SLP, CLC and Megan Martino, OT, CLC.

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This is Maureen Farrell and Heather O’Neal and this is The Milk Minute. We’re midwives and lactation professionals bringing you the most up-to-date evidence for all things lactation. So you can feel more confident about feeding your baby, body positivity, relationships, and mental health. Plus, we laugh a little or a lot along the way. So join us for another episode.

Heather O’Neal: Welcome to another episode of The Milk Minute Podcast.

Maureen Farrell: Today, we are going to talk about occupational therapy and speech pathology therapy with some specialists from one of our local NICU’s.

Heather O’Neal: Yeah. So did you even know that those people existed in the NICU to help your baby learn how to suck and prevent sucking and feeding issues?

Maureen Farrell:  I mean, I didn’t, I’m going into this blind, Heather. I had no idea.

Heather O’Neal: I mean, I honestly didn’t know the extent of it and I am so glad that they spent the time with us because everybody who is in the NICU needs to know what’s going on, including NICU nurses and labor and delivery nurses who might be sending a baby to the NICU, the more people that know about this that can help support their supportive measures is going to be amazing and better outcomes, better knowledge had by all. So today we are interviewing Katie Fluharty, who is a speech language pathologist, and we’re interviewing Megan Martino who’s an occupational therapist and they work together in a team in the NICU. But before we get into our interview with these two lovely ladies, we’re going to do a listener question.

And then at the end, make sure you stick around for another award in the alcove. Cause you never know the award might go to you.

Maureen Farrell: Okay. So our question today is from Holly. Holly says that her oldest daughter had a tough time nursing. Lactation consultants that she had a tongue tie, but the pediatrician and ENT said she didn’t. Now the baby is four and has trouble with certain sounds and her speech and really didn’t start communicating until the last year. So. That sounds frustrating. And Holly says, I don’t know who to believe. It’s so frustrating. And if the lactation consultants were correct, is that what’s impacting her speech? We’re with you. Because the reality is that the research on this is still out.

When we look at kids who have speech issues, a lot of them have tongue or lip ties. But when we look at a large population of babies with tongue or lip ties, not all of them have speech issues later.

Heather O’Neal: Right. And it seems it’s just very provider driven as far as preference. A lot of their own personal history with their patients, like maybe they had been releasing tongue ties and then saw that some of those kids were developing speech issues so they refrain from doing that. And that’s their personal provider choice. So we’re really with you on the frustration. There’s not a lot of experimental stuff out there because we’re not going to snip people’s tongues to see if we are going to give them a speech impediment. So, you know, let’s get into the interview and see if we can, if we can deduce anything from what these NICU specialists are going to tell us.

But Holly, hang in there. I do know that the community speech language pathologists that work with older children are magical. And I know a lot of people that are experiencing great results, having those therapies. So hang in there, keep us posted if you need anything. And yeah, let’s, let’s talk to these two gals and see what’s going on.

Hey Heather, can I take a minute to tell you about Happi Tummi? Oh, I really wish you would. Happi Tummi has natural products to help resolve the symptoms of colic, gas or constipation for babies. Oh, well that sounds great for babies that just are constantly in pain and discomfort from tummy troubles. And it happens, you know, as your baby is adjusting to its new environment, it’s tummy is going to get upset sometimes just like yours or mine.

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And if you want one for you, they have adult products,  too. No way. Yeah. That’s awesome. My cramps I’ve been a little bit much lately. Absolutely. So how do I get one? Head over to and use our discount code MILKMINUTE10 for 10% off. Oh, thank you. I’m going to go buy myself a menstrual cramp wrap.

Make your tummy happy. Such a happy tummy.

Without further ado, let’s meet our guests.

Megan Martino: My name is Megan Martino and I’m an occupational therapist. I currently practice in a neonatal setting. We work closely with a speech language pathologist in the area of feeding, and that includes breastfeeding and bottle feeding in that population. And with feeding we’re looking at kind of all the things that have to come together to make feeding successful for a tiny developing person and for the caregiver. So mom, dad, grandma, whoever that is.

Katie Fluharty: Yeah, I’m Katie Fluharty. I’m a speech language pathologist and I work with Megan in a neonatal intensive care, and we do frequently work together just in general, facilitating a development of newborns and preterm babies. My biggest focus for these little ones is pre feeding.

So feeding starts before you put a bottle or a baby to the breast, especially with a preterm baby. And then once they do start feeding, it’s just helping them to learn these feeding skills and to also facilitate family comfort and family education and providing feeding to the little ones.

Heather O’Neal: So that’s really, really interesting. And I have to be honest, I didn’t really know that. I didn’t know that that was even an option that you could start working as a speech language pathologist before they even have a bottle in their mouth or any kind of feeding is happening. So, you know, if I didn’t know that, then there’s a very good chance that most of our listener base didn’t know that.

So this just further proves that we needed to have this conversation today. So thank you both for being here.

Katie Fluharty: We’re glad to be here. We’re excited.

Maureen Farrell: So we know that you guys generally work together in the NICU, but do you think you could give us a quick differentiation between what a speech language pathologist does versus OT with infants?

Megan Martino: Yes in the neonatal intensive care unit, we, you are correct. We are very cohesive as a developmental therapy team. So there’s a lot of overlap in our disciplines across the board with feeding. Frequently as an OT, I will look at how is the baby positioned? Can we make it better so that both mom and baby are more comfortable? Are more ergonomically positioned? That we make the flow better for the baby in terms of the position of the baby or the position of the mom.

Katie Fluharty:  As a speech language pathologists, of course, first and foremost, the thing that we’re looking at is safety of feeding and swallowing. We’re looking for signs of aspiration or as the baby is feeding, any chance of the liquid going into the lungs.

So that’s the biggest difference, I think between she and I is looking at aspiration and her focus is more on positioning. You know, we use a lot of the same strategies to help those things, but we’re just looking at it in different ways so that we can make sure that the baby is feeding as successfully and comfortably as possible because what we don’t want is the feeding experience for baby, first and foremost, but also for mother, to be uncomfortable or difficult because we’re teaching these babies these skills for the first time.

And they’re going to learn that if this is an unpleasant experience, they’re not going to want to do it. And same thing with the mothers, you know, or, or caregivers. If it’s very difficult or the baby really struggles, it affects their self-esteem for feeding the baby and then it can often make them afraid. So, like Megan said, it’s just really protecting that mother, baby dyad as well for feeding.

Heather O’Neal: Wow. You know what? That makes so much sense that you guys would work together. And I feel like working as a team, even, we don’t work directly together during lactation consults, but we consult each other all the time. Because it just, sometimes she has a different idea than I have. And I know you guys are both also certified lactation counselors. Correct?

Katie Fluharty: Yes we are.

Heather O’Neal: So how about with those parents that are trying to breastfeed for the first time and what are some of the things that you guys are working on together as a team, trying to get that baby at the breast for the first time and what, like, from a CLC perspective also?

Katie Fluharty: The first thing I say is that a lot of times for us, because a lot of these babies we get consults on and they’re at the very early stages. So some of them are on a higher requirement for oxygen. So they’re not always feeding orally. Most of the time, they’re starting with a feeding tube. In that stage, we’re looking again at pre feeding.

So we’re looking at really encouraging the mother to be present, lots of skin to skin. And just like you can do non-nutritive with a pacifier, you can also do non-nutritive at the breast. So while that baby is skin to skin, putting the baby to the breast, letting the baby root around. Letting them lick, even letting mom express a little bit of the breast milk to the baby’s lips and letting them get a taste of that. So all of those are really good pre-feeding things that we’re often doing. Very first.

Heather O’Neal: I’m glad that you mentioned just letting the baby lick at the nipple and expressing little drops of milk, because I don’t think people realize what a big win that actually is when you’re in that situation. And if you don’t have the cheerleader team around you, like you all provide, you can feel like a failure. And I swear, half of our job is just telling people that they’re okay.

Maureen Farrell: So I’m going to like steer us over a little bit to a hot topic here. Let’s talk about tongue and lip ties. Cause this is like the hot topic, elephant in the room. You know, everybody who has a breastfeeding problem goes here first.

Yeah. I’m like, where do I even start with this? I guess just so the whole episode isn’t about this, I’m going to try to focus. But you know, we deal with a lot of parents who say they’ll get a diagnosis, they’ll get a revision. And then they’re kind of like, okay, we’re done. Right? And they’re shocked to learn that that’s not the end of the process. So I wanted to kind of pick your brains about what the period of relearning a latch looks like and some exercises we can do and things like that.

Katie Fluharty: So it is because the baby has learned how to suck with the limitation of the tongue tie. So, you know, motor planning and muscle memory, it’s a retraining period for them to figure out where to start and how to do that. Oftentimes, and again, in the NICU setting, we do see some of these kids but often, once they get their revision, they’re pretty close to going home. So we don’t do a whole lot of the therapeutic end of things. Like once the revision is done and they’re discharged, you know, what happens after that?

But speaking from the standpoint of feeding in the NICU with a tongue tie, we’ll identify it, talk with the physicians. If we really feel like it’s affecting functionality, then ENT is sometimes    consulted. And then of course the medical providers make a decision as to whether it is released or not.

Once it’s released, we try to see them with oral feedings to just really look and see. What are they still having issues with? What is that tongue doing? What’s it look like while they’re latching? Are they still having difficulty getting lip seal or getting that tongue really cupped up around there? And how do we, if they are, how do we provide them support to improve those things?

And, and oftentimes we go back to just providing them with cheek support and chin support and allowing them to feel into practice what it’s like to get that tongue into the appropriate position for feeding and latching onto the nipple.

Maureen Farrell: Quick interrupting question, but I’ve never seen this before so what is that cheek and chin support actually look like? Can you describe that to us?

Katie Fluharty: Yeah. So basically what you’re doing and oftentimes with chin support, what we’re doing is with one of the fingers, oftentimes your middle finger, while you’re holding the bottle, you’re using that little bit of upward pressure to really make sure that the jaw and the lips and the tongue are getting a good seal. Because we know that with bottle feeding and with breastfeeding, in order to get that milk to really start to flow, you have to have a negative oral pressure or you have to have a vacuum basically in the mouth to really make sure that that milk starts to come out. And if there’s any little bit of air that gets in there, it oftentimes allows them to not get that milk to flow as easily as it should.

So they often have a little bit of a harder time getting latched on and getting that milk to flow. And it requires a lot more energy for them to feed. So with the chin support, you’re just, again with the middle finger, kind of providing a little upward pressure on their chin and then with cheek support, that’s where often we get into a lot of positioning changes for feeding, because it takes a lot more to provide them cheek support.

And if you’re, you’re trying to provide them chin and cheeks support, I mean, it’s like, it’s like a puzzle with your fingers sometimes. So yeah. Yeah, it really is.

Megan Martino: So, especially if you’re breastfeeding, because then you have a breast kind of in your space too, and you have to figure out how to get your hand you know, under baby’s chin and around the cheeks and around your own breasts. So it’s tricky and it takes a lot of practice, which is what we stress to moms all the time. Especially with bottle feeding, obviously we’re not going to breastfeed your child in the NICU, but with bottle feeding especially, we say, we have fed hundreds of babies.

We have done this hundreds of times. So, if you feel like you feel funny or you look funny doing it, it’s okay. There is a complete learning curve and you’re going to get this and we are going to help you.

Heather O’Neal: Yeah. Yeah. That’s a good point. You know what I have found with the breastfeeding after, and these aren’t NICU babies per se, but with an infant that has a tongue tie released, and then I get a call for a private consult and the mom was like, this baby doesn’t know what to do with my nipple at all.

Like, they’re just kinda like all over the boob. So what I’ve found is the biggest challenge, but also the fix most of the time is trying to get that nipple to touch the roof of the mouth, to trigger them to actually suck. Where, you know, the bottle, it’s easy to kind of angle that nipple and touch the roof of the mouth and the baby’s little primal brain is like, Oh, I’m supposed to suck on this thing. But trying to get that nipple up there is so hard sometimes, especially if you’re transitioning from bottle to breast and your breasts aren’t being used that way all the time.

Maureen Farrell: Right. Especially if we have flatter nipples that won’t evert until there’s a suck, then it’s a challenge.

Heather O’Neal: Right. And like, I always tell parents, you can put your finger in your baby’s mouth and feel what the tongue is doing. You know, if they’re biting your finger, that’s a problem. Like no wonder your nipple feels like it’s gonna fall off. Like tell me what’s going on. And, you know, with the pandemic, we’ve had to do it virtually.

So I’m trying to get really good with my verbal cues about, tell me what you’re feeling on your finger from your baby’s tongue. And they’re like, wow, this is hard.

Katie Fluharty: It is. And often when we see a baby for their initial evaluation, that’s my favorite way to assess non-nutritive suck is by using my finger because it’s completely different to stick a pacifier in their mouth.

You can’t feel it. You know, you can imagine what it looks like and what their tongue is doing in there, but you can’t feel it. So it definitely is very helpful to use your finger and to actually know what that tongue is doing so that you can provide support if you need to.

Maureen Farrell: Yeah. And I mean, that’s what I do in every newborn exam. You know, just because we want to assess where they’re at with suck and every one of our listeners out there can do that. You know, you want to stick your finger in so that the pad of your finger is up on baby’s palate, kind of like slips right in there. And usually, you know, you can follow the palate back. There’s a little dip it fits in. And once you hit that, baby will start sucking. Hopefully. Right, baby should start sucking then.

And then if they’re not, maybe that’s a good time to engage a speech pathologist or an occupational therapist.

Heather O’Neal: Yeah. At that point, it’s kind of like phone a friend, you know. If you’re at home and your baby’s losing weight and can’t figure out how to suck on your finger, then I can’t tell you what your nipple is going to do that evening when the baby is starving.

So, you know, for these kids that, maybe they’re in the NICU and they have a little bit of a tongue tie and he’s consulted and they decide not to do a revision. Are there certain things that you do to increase mouth mobility, you know, beyond the cheek support? Like, do you do the stretching because a lot of families have questions for us. Like, should I be stretching this frenulum? And we’re like, ah?

Katie Fluharty: So to be completely honest, that’s not something that I do. And again, a lot of it is because our experience with tongue tie is pretty limited to just those kiddos that have one, and then really just figuring out what can we do to help them as far as facilitating improvement in their feeding.

So again, we’re just looking more at what supports that they might need to help with the latch and to help them learn and organize nutritive suckle. And then, so really we don’t do a lot of stretching. I know from looking at some of the research, they do say that doing some just lingual range of motion is beneficial, which is okay in an older child who can follow a little bit of direction, especially if you show them what they need to do, but, and a baby that’s difficult.

So when, when I think about lingual range of motion, for some of these kids, you’re going to do more of like a massage or making sure that the baby doesn’t build up scar tissue. Those sorts of things.

If it’s been released?

Megan Martino: Yeah. If it’s been released so they don’t re-adhere or build up scar tissue and then otherwise, just continuing to encourage and practice nonnutritive sucking.

We know that nutritive and non-nutritive sucking are not exactly the same, but there is some things that can carry over and there is benefit to providing them with practice for non-nutritive sucking to help facilitate nutritive sucking. Yeah.

Maureen Farrell: Yeah. And I think that’s a good point to make because we have, so much of our cultural messaging says, don’t let your baby use you as a pacifier. Which, you know, we have lots of opinions on, but for a lot of babies, that non-nutritive sucking is very important for them.

Katie Fluharty: Yeah. And, you know, I think we hear that a lot in the NICU because a lot of these babies can’t. So they’re not going to be feeding for weeks sometimes. So, you know, providing them with positive stimulation is a good thing. So, you know, we do use the pacifier a lot in the NICU, but it’s more out of necessity than, than it is, you know, just to keep the baby quiet.

Heather O’Neal: Yeah. Can we, yeah, let’s talk about some of the tools that you guys use and how you pick them. So maybe, since we’re talking about pacifiers, I mean, as a nurse that’s worked in the NICU before, I know it’s usually the straight nipple. Are there ever times that you choose a different pacifier and why?

Katie Fluharty: So we often talk to the family about, what’s their plan when they’re going to go home? Because we do use just a straight pacifier, straight nipple on the pacifier, cause that’s what we’re supplied with. And then also the bottles that we use are just throw away ones that look very similar to the pacifier with a straight nipple. So as part of, you know, my initial evaluation or when I very first meet the family, my question is, is what is your plan for baby for feeding when you go home?

Do you want to exclusively breastfeed or you going to breastfeeding and bottle feed? Are you okay with the pacifier? Because some parents don’t want their baby to have a pacifier for different reasons. So, and kind of get those ideas from them. And often what we try to do is keep everything consistent. You know, if they’re going to be, mom’s plan is that she wants to breastfeed and she wants to use a MAM or a NUK bottle, what I would say is just be consistent. Keep putting baby to breast, keep doing your skin to skin and encourage them to bring in a pacifier that is very similar to what they used once they go home.

Heather O’Neal: Yeah. And also side note, if you’re going to bring a MAM or a NUK, bring 10 of them. Because when the nipple falls on the floor, when the pacifier falls on the floor, you don’t want to have to wash it and reuse it cause that’s gross. Cause it’s a NICU. It’s not your house. So make sure there’s 10 of them so your plan can be followed through with, even if your baby chucks it for the sixth time that week, and the nurses are like little Brian, I’m so sick of your crap! Quit throwing your MAM overboard!

And then I had a question. Maybe you can confirm or deny. I think I read this somewhere, but you know brains. So I heard that the fast flow nipples were actually created for NICU babies at first. So they didn’t have to work as hard to get the milk out. So back in the day, you know, when they were like, Oh, we can make different nipples. Have you read that? Am I crazy? And can you bring us up to speed now as to why you try to stay away from the faster flows?

Megan Martino: Sure. I would not be surprised in the least bit if you have read that somewhere, because that I think is a huge misconception, even within people who are care providers in the NICU, that faster flow is better because the baby doesn’t have to work as hard to get the milk out. Yeah. That is complete fallacy for multiple reasons, primarily because in the NICU, we’re working with tiny developing brains.

So we’re not talking about even a 38 to 40 week newborn person. It’s all of these pathways in the brain are being laid as they are in the NICU developing. So they cannot, 99% of the time, manage a fast flow nipple. That would be like you standing in front of a fire hose and being like, Hey, go drink this.

So we like to protect that tiny developing brain that is laying all of those really awesome pathways, that is learning about feeding by just slowing it down. Especially with bottle feeding. Breastfeeding is so magical in that like mom’s body just like knows and adapts to what the baby is doing so often.

I mean, I know 100% of the time it doesn’t work that way, but especially for newborn babies, it just seems to be like, breastfeeding is this just magical in terms of so many things, but flow, especially. So when we’re transitioning back and forth between breastfeeding and bottle feeding, we certainly want to start the baby with a slow flow.

Not only to help that tiny developing brain, but to protect breastfeeding. To just slow it down. That’s usually, if we’re coming in to do a feeding assessment, that’s not my number one go to most of the time is, what are we eating on? Do we need to slow it down?

Heather O’Neal: Yeah, because here’s the thing. I don’t even want non NICU babies to use a fast flow because it impedes breastfeeding. They don’t want to wait. Their little brains don’t understand what full means in the correct timeframe that they should be feeling that. So who in the heck is the fast flow nipple for anyway?

Katie Fluharty: Yeah, I don’t know. That’s a great question.

Heather O’Neal: It’s for Maureen. When Maureen wants to chug out of a bottle, it’s for her. So why should parents not get freaked out when they see you working with their baby? Because anytime a parent sees a new care team member, they’re like, Oh God, what’s wrong? What’s going on? So what do you say to these people when they’re like, Oh, one more person working on my baby and they start flipping out.

Megan Martino: So we try to meet parents as soon as possible in the NICU, whether you have a 23 weeker and they’re two days old, or you have, you know, a 41 weeker. We try to meet them as soon as possible and my go-to with parents is who I am and why I’m there. And I am not here because there is something wrong with your baby.

I am here to help support your baby’s development so that they can do all of their really great baby things and you can take them home. So I think just trying to kind of put parents at ease, saying, I’m here to help your baby be the best baby that they can be is really a jumping off point. And then just telling them, these are the things that we’re going to work on in therapy while you’re in the NICU.

I think parents have very valid questions about. Oh, my gosh, what’s going on? Is this normal? Is this abnormal? And oftentimes it falls well within the realm of normal for that child’s development. So I think reassurance and reinforcement that what parents are doing at the bedside is great. And just being like that cheerleader.

Katie Fluharty: Yeah. And too, you know, because sometimes parents are afraid to do things with the baby. So it’s not the same feeling, even if you’ve had another child before. It’s not the same feeling and the same comfort level. So it’s really just saying, Hey, we’re here, but let us help you do this the first time, because it’s more important for you to do it than me to do it, but I want to be here to support you and let you know that you can do it.

Heather O’Neal: That’s awesome. And I think a lot of listeners think of our podcast is just breastfeeding, which most of it is geared towards breastfeeding, but the majority of people end up giving a bottle at some point. Whether supplemented by order or because they end up with a NICU baby that they didn’t plan on and you know, it happens.

So we’re so glad to have this resource for people and, you know, if somebody is looking at their new NICU baby today, what is the one thing that you want them to take away from this?

Megan Martino: It’s going to be okay. This is a very, very scary and stressful time. And you will probably remember 3% of your entire NICU stay. We as NICU staff, love your baby, and we want to see your baby grow from this little, tiny peanut to a little bit bigger peanut and go home with you. So we know this is scary and we know that you’re afraid and stressed out, but it’s going to be okay and we’re here to help you.

Katie Fluharty: And it’s okay to have those feelings, you know. Because sometimes they don’t want you to know they have those feelings. They want you to think that they’re fine. But it’s okay to have those feelings. It’s okay to talk about those feelings. It’s okay to ask for help. Because again, you know, you being at your baby’s bedside and you taking care of them as your way to bond with them during that time. So just be there and learn and ask for help when you need it. Cause that’s what we’re there to do.

Heather O’Neal: That makes me want to cry. That’s exactly what I would want to hear if I had just had a NICU baby. I would want to know that there was a team like you guys who actually cared about what was going to happen after they got home and made sure that you were preserving that journey along the way as all these different medical decisions were being made.

So thank you for all that you are doing for our NICU babies in West Virginia.

Katie Fluharty: Thank you. It was wonderful to be here.

Megan Martino: Thanks for having us.

Heather O’Neal: Maureen, did you know that any time I’ve ever tried a lube in my life, my vagina reacts like it’s mad at me? Yeah. You have mentioned that to me before. Yeah, I had, I used to call it AVD, angry vagina disorder, but the good news is I actually found a product that I really love and this is serious. I’m not joking.

This is not just something that I am saying to say on an ad. I love Uberlube. It’s a natural product that does not have any like artificial anything in it and it works with your body. And it actually lasts a pretty long time if you know what I mean? Yes, I do know what you mean, and I know that our listeners need lube kind of more than anything in the postpartum.

Like breastfeeding’s a dry time guys, and it’s not your fault. That’s kind of a normal side effect of breastfeeding, but it doesn’t mean your relationship has to suffer or even your relationship with yourself. Yeah. So get yourself some Uberlube by clicking the link in the show notes, or you can go to and enter the promo code MILKMINUTE. Happy lubing, everyone.

Maureen Farrell: All right. Hey, welcome to our awards in the alcove. This week, we have two awards because y’all hit the same milestone. So we’re going to give an award to both TJ and Gabriela for making their 12 month breastfeeding goal. Yeah. So happy 12 months to you both. And I don’t know, maybe your babies were born on the same day?

Oh, that’d be so cute. But I think we should give you guys the year long hero award. Oh, the year-long hero. You’ve been your baby’s hero for an entire year, and there’s no boobie that they love better. So congratulations to you two. And we couldn’t be more proud of you. Keep up the great work and send us a picture.

If you guys have a breastfeeding win that you want to share, you can always email us at and put in the subject line: My Breastfeeding Win. Bye-bye. See you later. Thanks for listening to The Milk Minute. If you haven’t already please like, subscribe and review our podcast wherever you listen.

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