An NICU SLP recently asked about resources for training neonatal nurses on feeding stress cues and stop signs. An SLP I know from Minnesota, Wendy, suggested the SLP take a look at the EFS. I responded to the post and share it with you here since it will let you now what you will hear about at our September 18-19 EFS training seminar in Hollywood, FL this year!
Thank you for your kind comments about The Early Feeding Skills Assessment Tool (EFS). It has evolved over the years as a wonderful guide to cue-based feeding in the NICU. I especially am proud of it because it looks at feeding from the infant’s perspective and is grounded in physiology. It reflects how I conceptualize feeding in the NICU, which I refer to as “infant-guided”, i.e., a dynamic approach based on contingent co-regulation between infant and caregiver. That maybe a parent/family member, a nurse, or a therapist.
A little background for list serve readers. Both working in NICUs at the time, Dr. Suzanne Thoyre and I first collaborated in the early 1980s about infant feeding in the NICU and how to describe infant’s feeding skills. When Dr. Thoyre, as a part of her NICU research, wanted to teach mothers how to describe their infant’s feeding problems during phone follow-up post-NICU discharge, the EFS began to take shape. After using the EFS for years and working with each other to continue to improve it, we published it and began to share it with others in 2005. With multiple revisions, as research and our learning continues, it is now used in several NICUs across the US, both by nurses and SLPs as they assess infant feeding, and as Wendy mentioned, with families to help them understand their infant’s communication and physiology during feeding, using a common language with staff.
The EFS assesses the preterm infant’s ability to maintain physiologic stability during feeding, remain engaged in feeding, organize oral-motor function and coordinate sucking and swallowing with breathing. The EFS, by the nature of its design, considers not just oral-motor skills but rather, the whole infant, from posture, to physiology, to breathing, to state, to coordination, to swallowing, to oral-motor skills as well.
Beyond that, it focuses on the integration of these domains for function, all within a developmental care framework. It is unique in that it recognizes the value of understanding the infant’s adaptive responses to the feeding task, and how they are instructive to the caregiver.
The tool is also based on dynamic systems theory (that multiple systems synergistically affect each other during feeding) and these systems are assessed dynamically throughout an entire feeding, to arrive at a gestalt. Capturing variability across the entire feeding is a critical part of the analysis/integration of information. The items are designed to capture the variability in the infant’s learning of the foundational components of feeding skills, the continuum of that learning, and the emergence of skills; so it assesses whether component skills are not observed, are emerging, or are indeed consistently expressed. It is often used serially to capture developmental progress in feeding over time.
The EFS leads the caregiver, by the nature of how it is designed, to the interventions that naturally flow from the results of the assessment. It profiles interventions to support adaptive function during feeding and swallowing, and therefore interventions for safety.
The EFS is user friendly in that it is not focused on understanding and identifying only isolated oral-motor components but rather making sense of what all caregivers “see” every day when they feed preterm infants–the infant’s communication/cues during feeding. It provides a common language about feeding terminology (such as what do we mean by an infant is “pacing” himself, or what is “coordinated”, for example) to help all team members, including families, get on the same page, so conversations and report have common meaning.
Our original manuscript from 2005 about the EFS is on my website under the Publications tab. We do require training on use of the tool (offered at least yearly) to assure implementation in keeping with its intended purpose and parameters. SLPs typically then go back and teach their own NICU staff with resources provided during the training. I am so glad the EFS has advanced infant-guided feeding in your NICU, Wendy!
I hope this is helpful.
Catherine S. Shaker, MS/CCC-SLP, BCS-S
Board Certified Specialist – Swallowing and Swallowing Disorders
Florida Hospital for Children