Problem-Solving with Catherine

QUESTION: I work in a special education setting with preschoolers and kindergarten age students.  I have a 6 year old student who choked on a hot dog at age 2.  He suffered anoxia and was being revived for nearly an hour.  He suffers from seizures and is on heavy seizure meds. He is quadriplegic and tube fed.  He has a PM valve and last year he would produce vocalizations at times when he was awake and alert. I was doing orofacial sensory stimulation to encourage movement of his articulators.  He tolerated it well and I did observe increased movements of his jaw tongue and lips.  Since last year his ability to remain awake and alert and to respond during school hours has really decreased. He has been less and less available for any kind of speech therapy.  He has a private nurse during school hours.  His mother does not communicate well with the school.  During this past winter he was absent for a few weeks.  I discovered through his teacher that he had been hospitalized for pneumonia. One of his private nurses shared that it was aspiration pneumonia and that he aspirated his saliva. Since then I have been very wary about doing oral-facial sensory stimulation that stimulates salivation.  We have an IEP meeting approaching soon and I plan to ask his mother about this and to get more information from her.  I am not sure what to do about providing oral sensory stimulation if what the nurse relayed is indeed accurate.  Any feedback from the group about this would be greatly appreciated.

ANSWER: With the clinical picture and co-morbidities you describe, his anoxic event likely caused a significant neurological insult. It is not uncommon that one of the sequelae with such children is swallowing impairment, such that the child does not have the postural/neuromotor, oral-pharyngeal-sensory-motor prerequisites that provide the essential underpinnings to swallow his saliva. He likely immuno-compromised which can increase risk for aspiration pneumonia. It is very possible he is aspirating his saliva at rest, as he may lack the ability to gain the needed mouth closure and tongue control to then drive the saliva bolus intraorally and pharyngeal, which causes accumulated saliva to then often take the path of least resistance toward the airway; he likely lacks then the sensory awareness to perceive saliva is approaching/entering his airway and perhaps the neuromotor skills to generate an effective cough. Good oral cares and oral hygiene will be essential to reduce the potential for bacteria-laden saliva to be aspirated.

I am not sure what oral-facial input you are providing, but it did not “cause”  the aspiration pneumonia itself, although in some children it may increase saliva production at that moment during therapy. Specific deep sensory input to muscles to support active movement may be provided from a neurodevelopmental treatment (NDT) perspective.  An NDT approach in this situation would be like “PT for not only the body but for the mouth” as one mom put it; this muscle based approach combines facilitation and inhibition and works directly on the muscles. I took an 8 week NDT course with PTs and OTs years ago to learn this approach, and it has been invaluable. With such children as you describe, using an NDT approach, I have observed clinical improvements in head/neck control, the driving force of the tongue, ability to use the cheeks/lips, and, as a result, swallowing.
You need more information to make sense of where to go next. Maybe mom would sign a release to allow your team to get more information, and contact his past therapists to better understand his co-morbidities, medical history/status. That may help you understand the changes in mental status you describe (his reduced alertness and awareness); all of this information should be the guide for you about continuing therapy or discontinuing therapy, and what to focus on in therapy, not the fact that he had aspiration PNA.

I hope this is helpful. You are doing a good job asking questions. As you get more information, you can continue problem-solving. He would be a complex and challenging patient for any of us.

Plan to attend Shaker Pediatric Swallowing and Feeding Seminar

Want to enhance your problem-solving and skills with completing a differential for your pediatric feeding/swallowing patients?
Join us for Pediatric Swallowing and Feeding: The Essentials in 2015! I’ll be teaching this seminar in Indianapolis, Seattle, Hollywood FL and Plano, TX this year. My colleague, Theresa Gager, will be there as well to share her thoughtful down to earth approach that has won her the heart of many parents and children☺ you’ll especially enjoy her discussion of Tools of the Trade – the many ways to facilitate feeding that involve the child and caregivers.

We’ll problem-solve tough cases as a group and we’ll bring you the latest evidence and years of practical experience with a variety of diagnoses and give you insights on how to assess, sort out relevant factors, make a treatment plan and then implement it.

Theresa and I absolutely love teaching this seminar together. We have worked together as therapists for over 25 years and continue to learn every day from the children we are fortunate to work with, and their families☺ Join us for a great learning opportunity!

We look forward to sharing our experiences and insights with you at Pediatric Swallowing and Feeding!!


Problem-Solving with Catherine: Video Swallow Studies

Problem-Solving with Catherine: Video Swallow Studies

Question: Do you find that sippy cups with spouts used during swallow study do not give the results you are looking for. . The swallow you get has a different pattern than open cup drinking and are you seeing a more immature oral phase. If the child is of the age that they should be drinking from an open cup do you find a more immature swallow with poor collecting. How do you report this and do you recommend open cup drinking to improve swallow maturity. If you are looking for aspiration do you think the immature pattern may be affecting this. I am looking more for your experience and information than answering your questions.

Answer: Good questions!

Looking at what the child is currently utilizing is a good place to start so we see a baseline that reflects the everyday feeding environment. A spouted sippy cup does typically promote different oral-motor patterns than an open cup, both for cheek/lip and tongue activity. It may also alter bolus size and flow rate, positively or negatively for that particular child.

Depending on the swallowing physiology observed, a spouted cup may actually promote a safer swallow for that child. The spout may provide more oral stability and/or promote more effective channeling of fluid through the oral cavity for that child. It is true that an open cup promotes more mature oral-motor patterns, but in the study we need to weigh intake, physiology, safety and developmental goals for that child with his history and co-morbidities. So on an interim basis, a sippy cup might be recommended, with the ultimate goal to work in therapy to provide oral-sensory-motor experiences and therapeutic trials with an open cup, if the study suggested that was appropriate and safe.

Delayed development of oral-motor patterns that support the emergence of more mature swallowing patterns can indeed affect physiology. During the swallow study, we are looking at the child’s swallowing physiology within the context of current level of development, his history and co-morbidities. While we may or may not capture aspiration events during the procedure, the nature of the physiology we observe should guide us to objectify potential interventions during the study. From there, the range of interventions useful for mealtime and those for focus in therapy, can be recommended.

I hope this is helpful.


Catherine S. Shaker, MS/CCC-SLP, BCS-S
Board Certified Specialist – Swallowing and Swallowing Disorders

Orlando, FL

SHAKER SEMINARS 2015 “Discover…Teach…Inspire”


May Indianapolis IN
               May 28-29   Pediatric Swallowing and Feeding
               May 30 Pediatric Swallow Studies
               May 31-June 1 NICU Swallowing and Feeding: In the Nursery and after Discharge  
June Boston MA
               June 19 Pediatric Swallow Studies
               June 20-21 NICU Swallowing and Feeding: In the Nursery and after Discharge  
               June 22-23 The Advanced Clinician in Pediatric Dysphagia: Taking it to the Next Level 
 July Seattle WA
               July 18 Pediatric Swallow Studies
               July 19-20 Pediatric Swallowing and Feeding
               July 21-22 The Advanced Clinician in Pediatric Dysphagia: Taking it to the Next Level 
August Houston TX
               August 13 Pediatric Swallow Studies
               August 14-15 NICU Swallowing and Feeding: In the Nursery and after Discharge  
               August 16-17 Tracheostomy and Swallowing
September Hollywood (near Miami and Ft. Lauderdale) FL
               September 17 Pediatric Swallow Studies
               September 18-19 The Early Feeding Skills Assessment Tool: A Guide to Cue-based Feeding in the NICU
               September 20-21 Pediatric Swallowing and Feeding
October Dallas TX
               October 23-24 Pediatric Swallowing and Feeding
               Oct 25 Pediatric Swallow Studies
               Oct 26-27 NICU Swallowing and Feeding: In the Nursery and after Discharge

October 2014 Updates from Catherine Shaker

As my traveling comes to a close for 2014, I look forward to some relaxation and time to catch my breath! Today in Florida it is breezy sunny and cool — 79 degrees!) My German Shepherds were happy to get out for a long walk in the early morning sunshine and enjoy nature with me. After I finish this update, I am headed outside to relax on the lanai by the pool with my husband and watch the palm trees sway!

The next few months of “R & R” let me recharge and also focus on catching up on things at home and time to write. My teaching schedule will resume in May 2015 and it will be a packed year with lots of opportunities to share my passion and dialogue with you. My schedule should be finalized soon so watch for the announcement on my website. If you are interested in having me bring my seminars to your facility/community, send me an e-mail and let me know some details and why. I enjoy getting across the country and having the opportunity to learn about the work you do. I hope if we have not met, that our paths will cross in 2015!

ASHA is right around the corner. If you are attending this year in Orlando, be sure to stop by to say hello at my presentation on Thursday November 20th on Cue-Based Feeding. It is always rewarding to share my passion with fellow SLPs and have an opportunity to contribute to my colleagues’ practice.

As the holiday season gets closer, enjoy the preparation and be sure to take time to relax.


Fall Updates from Florida

It’s hard to believe that October is almost here! Fall is approaching and I am already looking forward to the Holidays. It’s been a whirlwind year as I have travelled across the US and met so many therapists, both at national conferences and at my seminars.

I’ve been busy too at Florida Hospital for Children where my fulltime work allows me to touch so many families. I am amazed how much learn from them along the way. I reconnected with the father of one of one of my NICU babies, Carter, who was a 24 weeker, and is thriving at home and growing like a weed. Feeding is fun they tell me, as he plays with food on his high chair tray and eats off his little hands. That’s what I like to hear. Maybe I helped through the early guidance I offered at feedings in the NICU, building trust and supporting positive experiences that wired his brain toward, not away from, feeding. And now his success makes my day.

October is my last teaching series in 2014 and I am headed to Chicago. It is always heartwarming to return to the Midwest, where I spent much of my life until relocating to Orlando 5 years ago. I do hope I miss the snow, though I know from past experience it can snow in October in Illinois!

I’ll start teaching again in May 2015 and you’ll have plenty of advanced notice about where I will be and when. My break from teaching allows me to recharge, to spend some time relaxing, enjoy more Florida sunshine, reconnect with my family, including my German Shepherds, and write a few manuscripts to submit for publication. And I’ll be working on next year’s teaching schedule, too, and staying connected with all of you! If only there were more than 24 hours in a day!

In November, I am excited to be presenting at ASHA in Orlando on Cue-Base Feeding, with a focus on developing and sustaining a cue-based feeding program in the NICU. Like any other program we service, it requires our dedicated care and ongoing nurturing to continue to grow. In the NICU, how we cultivate our partnership with nurses and neonatologists is critically important, for each interaction about, and with, feeding matters. It matters to the infant’s brain and to the infant’s relationship with the family, and to long term feeding outcomes.

The challenges are there for all of us as we continue to problem-solve how to best support infant-guided feeding in the NICU. I especially look forward to meeting SLP colleagues after the session or when we pass in the conventions center and sharing our passion for helping the infants, children and families we are fortunate to support.

Enjoy the season ahead and stay in touch!


Brain Oriented Care in NICU 2014

I wanted to share with those of you who are part of an NICU team or provide services for NICU graduates an article that was just published. Those of you have an interest in neuroprotection for fragile adults will also find it interesting. 

Bader, L. (2014) Brain-Oriented Care in the NICU: A Case Study. Neonatal Network Sept/Oct 2014, 263-267 (Brain Oriented Care in NICU 2014)

Brain-oriented care, or neuroprotection, is fairly new to the NICU, yet as the author states, neuroprotection encompasses all the interventions that promote development of the brain. Because our NICU infants are wiring their brains outside the womb, every experience matters. Especially when it comes to feeding. The author makes the connection to infant-guided feeding, an approach we all need to advocate minimizing the physiologic stress associated with learning to feed in the NICU, and indeed after discharge. Unfortunately the physiologic stress that many NICU infants experience when fed using a volume-driven approach instead, can wire the brain away from feeding. The feeding outcomes of NICU infants, which are poor, make it imperative that we be a part of the change in our NICUs to listen to the infant’s communication and provide the relationship-based care, especially  with feeding, that allows the preterm infant’s brain to wire in an adaptive not a maladaptive way.

I hope you find this informative.


Q & A Time: Problem-Solving with Catherine: Weak Suck

Q & A Time: Problem-Solving with Catherine

Question: I am seeing a newborn at 38 weeks now day of life # 31 baby. Has weak suck. Is able to bring liquid into mouth but no coordination. to swallow. Most liquid pools in mouth and is spit out. Baby tires quickly. Baby has many other health issues including predominant extensor tone, cardiac, chromosomal abnormality-only 50 cases known-life expectancy is very low). I would appreciate any suggestions re: stimulation of swallow, feeding intervention.

This certainly appears to be a challenging newborn. From what you describe, there appear to be significant issues for swallowing safety and oral feeding may not be indicated right now.

Many sick infants with such a presentation actually have underlying low tone proximally. Thus the hypotonia that likely exists in the head/neck provides a poor base of support for the trachea and for the swallowing mechanism. It is likely that both the intrinsic and extrinsic tongue muscles are hypotonic. As a result not only will the suck be weak, but the swallow will be affected (decreased BOT for posterior propulsion, decreased pharyngeal compression and motility related to reduced control of the constrictors, etc.). Due to underlying low tone throughout the upper body, it is likely that there are respiratory issues that may result in increased work of breathing, that might compromise timing of the swallow-breathe sequence.

What is his actual diagnosis? What are his pharyngeal reflexes like? Often in such babies those reflexes are unreliable. Does he swallow his saliva? Sounds like it may also pool as does fluid offered. What is his state regulation like? What about work of breathing? What is the status of his airway —is there any auditory suggestion that he is not maintaining it? Not uncommon with such a postural presentation.

Given what we know, I’d suggest a swallow study. It is likely there is a delay in the initiation of the swallow, along with reduced pharyngeal motility and clearing, and the risk for silent aspiration, given what you describe, is high. This information about his swallow will be important to your intervention plan and for the discharge plan, especially since he has already been hospitalized a month.
I’d also recommend to the neo that we limit to gavage feedings only, with swallowing trials (as safety permits) by the SLP. Intervention would include a good postural base (via swaddling and positioning–well-supported side lying may help tremendously; check with OT/PT as needed), work on the intrinsic and extrinsic tongue muscles (via deep pressure input, direct and indirect tapping, direct NDT techniques to the muscle groups of the tongue to improve stability and control); the cheek/lip muscles may benefit from direct input as well, as they are likely also to be hypotonic given what we know. This is not to say that the cheeks/lips need to be active (they are not active in normal infants until 3-4 months of age) but they do provide postural stability for the tongue during young infant feeding. If the pharyngeal responses are diminished, again likely with this presentation, I have found some direct sensory-motor input can be helpful. Depending upon results/impressions from the swallow study, one might consider, after providing the sensory-motor preparation just described, offering trace amounts (single sucks at best) of fluid via a slow flow nipple, which would have been trailed in Radiology (Dr. Brown’s Premie Flow level P or Enfamil slow flow) and observe.
The other issues are of course ethical and quality of life if indeed life expectancy is limited with his diagnosis. So close collaboration with the neos and nurses, and family, regarding safety issues and impact is essential. Volume won’t be the goal if swallowing trials are initiated. He will need some form of tube feeding for his nutrition. Likely this would be an NG if life expectancy is short and prognosis overall is poor, but in some cases a PEG is placed. On-going therapy that may eventually be more monitoring or episodic, is typically provided after discharge.

It’s a rainy day in Florida…

…and cloudy, which is rare. Sort of nice though to just make me want to kick back and relax! The neighborhood children are all back in school and 2014 is more than half gone. What a fast year this has been! My 2015 seminar schedule is almost finalized and I am already looking ahead to 2016.

In 2015 I’ll again be teaching my specialty courses, including “The Early Feeding Skills Assessment Tool: A Guide to Cue-Based feeding in the NICU” in Houston in August, with my colleague and friend, Suzanne Thoyre, PhD, RN. We so enjoy the problem-solving that the nurse and therapist audience experiences watching videos of infants feeding, scoring the EFS and planning infant-guided cue-based feeding care. Michele Clouse, who teaches her course “Tracheostomy and Swallowing: Pediatrics to Adult” will join us in Houston and bring her down to earth hands on approach to trachs that past attendees remark makes such good sense. I’ll also teach my one day “Pediatric Videoswallow Studies” seminar in Houston since that’s been highly requested. Our focus will be on physiology and its impairment in infants and children, not just on aspiration.

You will also find me in Wilmington DE in September 2015 where I’ll offer my newest seminar “The Advanced Clinician in Pediatric Dysphagia”. Its first offering in Dallas this year was so well received, and attended by both seasoned and new clinicians. What the group liked best was the opportunity to go into depth on both hot topics and their own case studies, and share clinical insights. We all waked away with our brains “on fire” from thinking and problem-solving. It’s so important that we have the tools to provide expert consults these days, as that is truly the value we add to our patients’ care. To do that, we need well-honed problem-solving skills to complete a differential of what is going on, consider multiple co-morbidities and a range of interventions. It’s the way we leave an impression with our medical colleagues that leaves them thinking about YOU, “The next time I have a challenging pediatric patient, I want HER/HIS input!”

More to come regarding my 2015 schedule soon….including the West Coast, North Carolina, Dallas and other exciting places. Let me know if you’d like me to consider coming to your hospital in the future.

Have a great weekend!


Q & A Time: Problem Solving with Catherine

QUESTION: I am posting this for a colleague that works in our NICU department, we’d appreciate any insight you might have!

“Can there be significance to infant’s with tongue tip elevation as the preferred position while at rest?  We currently have two infants on our NICU caseload that consistently hold this position.  It is interfering with feeding as the infants both root but will infrequently bring their tongues down for nipple acceptance.  They are both from a twin gestation and were born between 28-30 weeks.  Neither have an oxygen need.  Any thoughts?”

This is an adaptive or compensatory behavior often seen in preterms, especially those born <28 weeks, but even in late preterms. It is associated with increased WOB and/or an increased respiratory rate. One of my favorite neonatologists, Dr. Ragatz, who was my mentor almost 30 years ago, loved to “think along with” me about how respiratory co-morbidities affect breathing. As a marathon runner, too, he concurred with me on this. Placing the tongue tip on the alveolar ridge provides the infant with  a point of stability for the tongue, and has an  impact on many of the muscles of the head/neck, including those that stabilize the shoulder girdle. This biomechanically creates the feeling of a more open airway.  No one has studied this phenomenon but a pulmonologist and several skilled neonatal OTs and PTs have agreed with this hypothesis. Our infants find ways to help themselves without someone telling them; this is an example, as is the spontaneous use of pursed lip breathing by preterms who need to blow off C02; adults with COPD are often taught this by RTs. Dr. Ragatz found it fascinating that what he reported experiencing while running the Boston Marathon was what we see some of preemies do.

When we see this behavior, it is communication to us that the infant is choosing to pause his sucking to breathe. And so we respect this, allow him the pause as long as he wishes, letting him signal his readiness to return to sucking via his active rooting on the nipple which is kept touching the corner of his lip during the pause. We then create a feeding “environment” that reduces his need to recruit this adaptive behavior. We do this by utilizing a swaddled elevated sidelying position, a slower flow nipple, and contingent co-regulated pacing to support a frequent series of deep breaths.

Think about the infant’s behavior not as “interfering” with feeding, but as the infant guiding you as the caregiver. When feeding the infant is perceived and valued as a relationship between the infant and the caregiver, the feeding experience builds trust and positive sensory-motor learning for the infant. This is the way we improve post-NICU feeding outcomes and support the parent-infant relationship in ways that have long-lasting effects.

I hope this is helpful.

Catherine S. Shaker, MS/CCC-SLP, BCS-S
Board Certified Specialist – Swallowing
Florida Hospital for Children
Orlando, Florida

Spread the word to your NICU nurses! I am pleased to add the opportunity for NICU nurses to join us to problem-solve!

I am adding a day of nurse participation as part of my NICU seminar. Therapists will continue to participate in two days of “NICU Swallowing and Feeding: In the Nursery and After Discharge. But now, on day two, neonatal nurses can join us for just the second day only, devoted to feeding/swallowing intervention! The collaboration and sharing of the evidence-base and perspectives and will add value and insight to what we can accomplish alone. A neonatal nurse I met recently at my New Jersey NICU seminar encouraged me to offer day two as a way to share the evidence base about interventions directly with nurses. The nurses will receive nursing CEUs and we can all benefit from learning along with each other.

It’s called “NICU Feeding Essentials: Using the Evidence-base to Inform Your Nursing Practice”. And what a fun day it will be!
I’m kicking this off starting in August in Orange, California and then in Phoenix in September and in the Chicago area in October. If you have ideas for other seminars to help meet your professional continuing education needs, let me know!

I hope you are enjoying this wonderful summer!

Problem-Solving with Catherine

Problem-Solving with Catherine


Question from therapist:

I have performed a swallow evaluation on a 36 week preterm on supplemental O2 1L 21%Fio2 almost a week ago ( he was 35 at the time). The report I received was that the baby was not interested in PO. However, my assessment with slow flow nipple with the use of side lying and strict external pacing. 1 suck one swallow / cough and choke followed by desaturation to low 80s. Recover in 20 seconds. The next two sessions Dr. Brown preemie with 5 minutes of short sucking bursts with pacing every suck with desaturation to 50%!!! Self-corrected with some external help after almost 30 second. My recommendation is to hold PO feed until next week, RNs did not like that and told me today that they tried last night and he took 11 mL and choked and desaturated several times. My question is: is it really worth it? I don’t plan on doing a video swallow study because I know he aspirates, I am just waiting for him to May be mature a little bit and hopefully with time his swallow function and respiratory status will improve. Other than slow flow nipple/ external pacing and side lying, what other strategies we can implement to help this little guy?
He does very well in NNS via pacifier.

Response from Catherine:

We need to know more about his history, especially his GA and his co-morbidities, respiratory hx and behaviors (hx of ventilation?  Progression to low flow nasal cannulae – was it difficult for him to wean? Baseline RR and WOB at rest, WOB with pacifier? is he on any diuretics? hx of PDA ligation?), his postural control and state regulation, for example, to problem-solve.

Knowing he is 36 weeks PMA and having adverse overt events is indeed concerning. Without the bigger context of his hx, it makes it challenging to complete a differential. A set of data in the context of a different history and a different set of co-morbidities will often yield a different POC.

In my experience it is not typical or a variant of maturity at 36 weeks PMA to display the physiologic decompensation you and RNs report, especially given the interventions described. If they are going to continue to feed him we need to objectify the swallowing physiology. A swallow study would not be to see if he aspirates. It should allow us, as Jim Coyle has taught us, to look for a biomechanical impairment and any form of bolus mis-direction, not just airway mis-direction, that may lead to the decompensation observed and then allow us to objectify the impact of carefully titrated interventions, and to determine the etiolog(ies) for bolus mis-direction or perhaps prolonged breath holding.

Tell us more :-)
I hope this is helpful.



Response from therapist:


Thank you so much Catherine for responding to my post. Here is more information:

His GA 27/ 2 days with RDS with APGAR 1 minute 8 – 5 minutes 9 He  was placed on NCPAP  for a week then followed by HFNC for a couple of more weeks. This last month, he has been on O2 NC ( 1L / FIO2 21 %. ECHO was done 3 weeks ago with small PDA. Baby is also SGA.  Chest X-ray about two weeks ago : moderate diffuse interstitial and airspace disease. last week, improved resolution of the bilateral pulmonary opacities.  They just started him on Diuretics on May 28th. He had two HUS that were normal. This baby is in a very calm state, does not show hunger cues and/or hand to mouth exploration. He does have a root reflex. He is alert the entire feed, not very engaged though. He has very short sucking bursts 2-3  this poor thing is very cautious with his sucking as  if he knows it is not going to go well. So he is not really that eager feeder that goes to town and forgets to breathe. His suck strength and length with a pacifier is excellent. And state regulation is normal with the pacifier. Oral exam is unremarkable. About the formal swallow study, your point is reasonable. However from my previous experience in this NICU. The information that I get from the study is oftentimes misinterpreted and used against my judgment. I had a baby in the past that I did a video swallow study on and he had consistent penetration 50% of the time with the slow flow nipple / 10 % of the time with Dr. Brown preemie and my recommendations was to use Dr. Brown Preemie with side lying and provide 5 minutes break before resuming the last 10 ccs (because that is when the baby gets disorganized and start choking) and the baby ended up NPO for PEG placement. They concluded that the baby is micro aspirating and no matter what I say and how I explain it. RNs just would not feed him. I would see him for his AM feed and that is about all he got all week long until he was transferred to a different hospital for the PEG placement. I tried to contact the mother to educate her about her son’s condition and how he can still bottle feed and she was so busy, would not return my call.  I might sound unreasonable but I am considering the study as the last resort, perhaps after a couple of more weeks when I know that that is as good as it gets!


Response from Catherine


Thanks for the great detailed history. This helps me focus and use the infant’s specific history and co-morbidities to guide my thoughts. I find that every day in the NICU this is the process that best supports my critical thinking :-)

I am not surprised that he is under 28 weeks given the complex clinical presentation you described in your original post. His respiratory course described and the fact that he still requires flow and is on chronic diuretics suggest that respiratory co-morbidities are paramount; he may indeed have met the criteria for CLD. The PDA, though it is small is also likely driving increased WOB.

Some of his disengagement you describe (“not showing hunger cues) may be due to WOB , even if it appears somewhat subtle at times, which can often inhibit the  drive to suck. This is a likely etiology given that his non-nutritive suck is described as well-developed and effective. I find this is often the case with our infants with significant respiratory co-morbidities and often our “healthy preterms” as well. Sometimes “sucking skill” can actually predispose such infants to bolus mis-direction. That is why focusing on the suck as the focal point for a feeding assessment can be limiting, or even cause one to label a pattern such as “wide jaw excursions with sucking”  as arbitrarily “pathologic/abnormal” when it is actually may be for that infant, an  adaptive/purposeful behavior that the infant uses in response to swallow-breathe incoordination. You make  a great example of the short sucking bursts you describe that he uses — he is “very cautious with his sucking as  if he knows it is not going to go well”–that is, the short sucking bursts do not reflect pathology –i.e.,  the inability to sustain a long sucking burst–though some may think it is pathology if they just focus on his sucking without looking at the context/co-morbidities. Actually for him, the short sucking bursts reflect “good thinking” on his part, as I say, to parents :-)

I was especially impressed by the fact that despite your interventions, he continues to have adverse overt events. For many preterms, slow flow rate with contingent co-regulated pacing as you describe can avert decompensation. We always as NICU SLPs use those interventions, and don’t rush to radiology, but when the fundamental interventions do not ameliorate the decompensation, that is highly concerning, as you undoubtedly told your NICU staff. Every experience the infant has matters. So if they continue to feed him and each time he experiences negative learning, he is wiring his brain away from eating. We know the neurons that fire together wire together. It is highly likely that continued feeding under these “conditions” can be a pathway to aversions down the road. that’s where some  researchers are focusing:

Smith G.C., Gutovich, J. et al (2011) Neonatal intensive care unit stress is associated with brain development in preterm infants .Annals of Neurology. 70(4), 541-549.

Thoyre, S.M. (2007) Feeding outcomes of extremely premature infants after neonatal intensive care. JOGNN, 36(4): 366-375.

By advocating to obtain objective data via an instrumental assessment, you will have more information to rule in or rule out what the possible etiologies might be, what specifically may be happening to predispose him to bolus mis-direction and then observe if any further interventions (e.g., maybe only single sucks at a time for now?) serve to avert the negative experiences. If we do not advocate for further workup, they will likely continue to feed him as they are, and at what cost to the infant, and we don’t fully understand his physiology. Sometime s infants with this presentation are purposefully using a delay in swallow initiation to get that last breath in, much like COPD-ers. Knowing that, i.e., why the events might be occurring, is important and guides interventions.

I so understand your frustration with the responses we sometimes received to our recommendations after both clinical and instrumental assessments. But the only way we change that is to keep having dialogue and trying our best for each patient as you are trying to do. it is always a journey working in the NICU, I say, not a destination -)  I have these same struggles every day. I worry for him that if you wait to sort this out until  “after a couple of more weeks”, his learning and outcomes could be altered quite adversely.

Thanks so much Dina for your thoughtfulness and this interesting but unfortunately too common dilemma. I hope this is helpful and apologize it is so long! As you can see, the NICU is my passion and I love problem-solving.

Catherine S. Shaker, MS/CCC-SLP, BRS-S
Board Recognized Specialist – Swallowing and Swallowing Disorders
Florida Hospital for Children
Orlando, FL

Problem-Solving with Catherine

Problem-Solving with Catherine
Question: Apparently our hospital has a new grant for ‘Music Therapy’. I thought it was for the Pedi cancer patients, but I see one of my NICU babies is on their list. Someone comes twice a day and has a pacifier connected to a machine that plays music when the infant sucks hard enough. Per the nurses report, the music therapist said the infant was ‘getting better’ w his sucking (stronger? longer? NNS?). This particular baby is a 48 wk., 4 month old (born at 32 weeks/twin). He is still <5 lbs. and has BPD, no endurance, reflux and an aversion to nipple feeding (GT was planned for this past Monday, but he has a UTI). I feel like this topic has been address before here, but I am just not capable of figuring out how to find it. I was wondering what the feeling is from our community – helpful and good, tiring and bad, case by case?

Also, I am not sure how pt.’s are chosen to participate in the music therapy and I only became aware of it yesterday because infants father thinks it tires baby out and “Nobody cares what (he) thinks.” I have a call out to the music therapist herself too. Any input would be appreciated! Danielle
 Music Therapy in the NICU often includes PALS (Pacifier Assisted Lullaby) as you mentioned below, though it may include only the playing of music and singing while the infant is held by the Music Therapist.

We must all be thoughtful as we evaluate devices that are designed or marketed to develop a skill. It is the thoughtful use of a modality, or the thoughtful decision not to use it, based on the clinical assessment of our patient and the evidence, that should be our guide, both in the NICU or in any other level of care in which SLPs are a part of the team.

My NICU clinical experience for almost 30 years suggests that PAL (Pacifier Assisted Lullaby)  is not an answer for the feeding/swallowing problems preterm infants present, and may actually inhibit functional skill (i.e., feeding). The issue for preterm infants is more complex than a “sucking problem.” Feeding problems in the NICU are rarely so simple, though sometimes a “poor suck” is unfortunately perceived as the reason for many of them. Learning to feed, both effectively and safely, is a complex, multifaceted challenge for preterm infants.1

I have been part of the team in two large level III NICUs, and many of those babies have been extremely preterm. Many have respiratory distress syndrome (RDS) or CLD (Chronic Lung Disease), requiring intubation and ventilation, and/or need supplemental oxygen in the course of their recovery. We have not observed a direct detrimental effect on non-nutritive suck (NNS). These infants typically demonstrate effective non-nutritive sucking when ready to initiate bottle feeding, with respiratory issues being the paramount barriers. We have found that the NNS typically emerges with development and positive support during care. For all infants, our nurses provide excellent oral care, including developmentally appropriate hand-to-mouth, rooting and pacifier activities, to support development of non-nutritive sucking. For infants with delays in onset of oral feeding due to medical status or those profiled as likely to be high-risk fragile feeders, the speech-language pathologist is added to the team to provide positive early pre-feeding and graded swallowing experiences. This helps the infant make the transition to nutritive sucking more safely and effectively.2

The challenges preterms encounter in learning to feed are most often the direct sequelae of residual respiratory problems. These problems (e.g., tachypnea, increased work of breathing, compensatory breathing behaviors, breath-holding) jeopardize the coordination of sucking, swallowing and breathing. 1  This can lead to respiratory fatigue and incoordination, or indeed adverse events such as choking, coughing and color change. Even infants with excellent NNS can have significant problems learning to suck nutritively because their drive to suck is often stronger than their physiologic sense of oxygenation.3

Very often the co-morbidities of early gestation, lower birth weight and attendant respiratory sequelae make feeding a challenge. The NNS, for which PAL was developed, has not been the issue delaying discharge.

It is also important to recognize that the NNS and the nutritive suck are very different in their rate and rhythm due to the addition of fluid with nutritive sucking. This renders non-nutritive and nutritive sucking different developmental skills. Lingual patterns on ultrasound have shown significantly greater displacements and excursions when a preterm infant was sucking nutritively vs. non-nutritively on a pacifier.4

The NNS is not in itself a predictor of nutritive success (i.e., bottle feeding), research has found.5 
NNS is just one of several domains that require consideration when contemplating the introduction of oral feeding. While found to be helpful, typical non-nutritive interventions have not been shown to decrease length of stay.6

A recent study reported that a non-nutritive stimulation program in an NICU did not result in earlier weaning from an nasogastric (NG) tube or earlier discharge when compared to similar infants without that intervention.7

In addition, PAL is designed to foster, and has as its outcomes, longer sucking bursts. Longer sucking bursts are problematic for the preterm. Longer sucking bursts may inadvertently, and often do,  result in respiratory decompensation, increase in  WOB and overall respiratory effort. This “drain” on the infant’s respiratory reserves can have detrimental effects on the functional skill of feeding,8 as PAL is often provided just prior to a feeding. During PALS, the focus  by the Music Therapist is only on sucking, and as a result, the infant’s communication about its effects on breathing may not be recognized or understood by the Music Therapist


Also, during PAL, it is likely at the preterm infant is not able to stop on his own at the appropriate junctures to take a series of deep breaths. This is directly related to immaturity, i.e. the drive to suck can inhibit the drive to breathe in the preterm, as he cannot register changes in CO2 versus O2, which can be a by-product of continuous sucking. So we often see a continuous sucking pattern with the pacifier and with PO feeding.9

While continuous sucking may sound like a hallmark of skill, in the preterm infant it can destabilize the autonomic system, lead to breath-holding or insufficient breaths, which can lead to desaturation, and potentially a cascade of events leading to decompensation.

So sucking, faster sucking or engaging in longer sucking bursts, is not necessarily good for the preterm and typically is not. Sucking can’t be looked at in isolation, as it is part of a dynamic physiologic event that has multiple system implications/effects. 10

When the focus is on sucking itself, i.e. with PAL, we are not providing the preterm with the careful support required to integrate breathing with sucking. Then sucking activities provided can actually be detrimental to motor-learning, and potentially increase stress on a physiologic level.11  This can then lay down neural pathways that, instead of facilitating positive learning, may move the infant away from learning to feed.12

While it may seem to some that enhancing sucking can be the answer for feeding issues that delay discharge, it is just not that simple. NICU infants learning to feed require dynamic, infant-guided supportive strategies during both pacifier sucking and during feeding, based on watchful vigilance and continuous feedback from the infant. The focus is on physiologic stability, active participation of the infant, and coordination of sucking with swallowing and breathing.5
This approach is more likely to promote readiness for  and eventual swallowing safety, support adequate nutrition, and result in the earlier discharges we have seen in the NICUs I have been fortunate to work in.

As you know, supporting successful feeding for preterm infants goes way beyond sucking. For those infants who indeed do have “sucking” problems, then the involvement of the SLP, who can problem-solve with reflective/critical thinking, and support the integration of sucking with breathing, in preparation for eventual PO feeding,  is more supportive and more beneficial for sensory-motor learning than a referral for PAL, in my opinion.

1. Shaker, C.S. (2013) Reading the Feeding. The ASHA Leader – American Speech-Language-Hearing Association.
2. Shaker, C.S. (2013) Cue-Based Co-regulated Feeding in the NICU: Supporting Parents in Learning to Feed Their Preterm Infant. Newborn and Infant Nursing Reviews (2013) 13 (1): 51-5
3. Shaker, C.S. (2012) Feed Me Only When I’m Cueing: Moving Away From a Volume Driven Culture in the NICU. Neonatal Intensive Care, Journal of Perinatology-Neonatology, 25 (3) May-June, 27-32.
4. Miller, J.L., Kang, S.M. (2007).Preliminary ultrasound observation of lingual movement patterns during non-nutritive versus non-nutritive sucking in a premature infant. Dysphagia, 22: 150-60.
5. Lau, C., Kusnierczyk, I. (2001). Quantitative evaluation of infants’ non-nutritive and nutritive sucking. Dysphagia, 16: 58-67.
6. Fucile, S., Gisel, E.G., Lau, C. (2002). Oral stimulation accelerates the transition from tube to oral feeding in pre-term infants. Journal of Pediatrics, 141: 230-36.
7. Bragelian, R., Rokke, W., Markestad, T. (2007). Stimulation of sucking and swallowing to promote oral feeding in premature infants. Acta Paediatrica, 96: 1430-32.
8. Thoyre, S.M., Shaker, C.S., Pridham, K.F. (2005). The early feeding skills assessment for preterm infants. Neonatal Network, 24: 7-16.
9. Shaker, C.S. (2010) Improving Feeding Outcomes in the NICU: Moving from a Volume-Driven to an Infant-Driven Approach. American Speech, Language, Hearing Association. Swallowing Disorders Division 13 Perspectives – Oct
10. Shaker, C.S. (1999) Nipple feeding preterm infants: An individualized, developmentally supportive approach. Neonatal Network, 18(3), 15-22.
11. Smith G.C., Gutovich, J. et al (2011) Neonatal intensive care unit stress is associated with brain development in preterm infants .Annals of Neurology. 70(4), 541-549.
12. Browne, J. V., & Ross, E. S. (2011). Eating as a neurodevelopmental process for high-risk newborns. Clinics in Perinatology, 38(4), 731.

I hope this is helpful. Good critical thinking on your part!

Catherine S. Shaker, MS/CCC-SLP, BCS-S
Board Certified Specialist – Swallowing and Swallowing Disorders
Florida Hospital for Children
Orlando, FL

NANT Conference 2014 in Atlanta

Just returned from the National Association of Neonatal Therapists Conference in Atlanta. My presentation “The Advanced Clinician in Neonatal Swallowing/Feeding: Taking It to the Next Level was well-received. It shared the multiple ways we add value and how we can articulate the need for our involvement in the NICU. In July I’ll be expanding this topic for my newest seminar “The Advanced Clinician in Pediatric Dysphagia: Taking It to the Next level” in Dallas. I am excited about this seminar as it will be the springboard for Hot Topics, clinical reasoning with complex patients and case discussions including those attendees bring. Check out the details in my 2014 brochure on my website

The NANT conference was wonderful and packed full of information about our NICU babies and the work we do as NICU therapists. I had the opportunity to share my passion with Lynn Wolf and Robin Glass over good food, which was a highlight of the weekend. Wolf and Glass shared their new methodology for when feeding on HFNC (high flow nasal cannulae) might be considered and the clinical reasoning that is essential in decision-making. We also heard the latest on bubble CPAP, kangaroo care and developmental outcomes. All very interesting. I’ll bring highlights from the NANT conference to my NICU and Cue-based Feeding seminars in 2014. I hope to see you this year! Catherine

NEW in 2014! The Advanced Clinician in Pediatric Dysphagia: Taking it to the Next Level

NEW in 2014!
The Advanced Clinician in Pediatric Dysphagia: Taking it to the Next Level
Day One: Complex cases, Hot Topics

       Day Two: Ask the Experts (Bring Your Cases!)

This timely seminar will bring you essential information to enhance your effectiveness as a specialist in pediatric swallowing and feeding and a sought-after member of your team. What makes an advanced clinician “advanced”? It’s not just having information. It’s how you use the information you have, what sense you make of it in light of the big picture, and how you apply it dynamically to each pediatric patient. Correlating co-morbidities, clinical data and the infant/child’s behaviors is at the heart of completing a good differential. Apply critical problem-solving skills to complex cases, explore hot topics in pediatric dysphagia and then discuss your challenging patients with the experts and your peers. Come ready to take it to the next level!
1. Explain the use of system-based differential diagnosis specific to clinical presentation of feeding/swallowing problems.
2. Discuss the dynamic problem-solving process essential to effective clinical management.
3. Apply critical reflective thinking to 5 case presentations
4. List 5 strategies to enhance your effectiveness in your pediatric practice setting.
5. Explain key concepts/challenges/evidence specify to “hot topics” in Peds dysphagia.
6. Complete a differential on your patient using the problem-solving approach discussed.

***attendees are encouraged to bring case study in predetermined format, i.e. written, or on CD/DVD