Tag Archives: Catherine Shaker courses

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!
Catherine

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.

Thanks
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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.

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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!

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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
Catherine S. Shaker, MS/CCC-SLP, BRS-S
Board Recognized Specialist – Swallowing and Swallowing Disorders
Florida Hospital for Children
Orlando, FL
http://www.Shaker4SwallowingandFeeding.com

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
Answer:
 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.

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

www.Shaker4SwallowingandFeeding.com

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 http://www.Shaker4SwallowingandFeeding.com

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!
Outcomes:
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

Q & A: Problem-Solving with Catherine

Q & A: Problem-Solving with Catherine

Question: I have a question for you. I work in a Level 2 special care nursery; it is staffed with PRN OTs and PTs who specialize here. A nurse on the unit has asked me for a guide to knowing when to refer for therapy services, based on evidence based research. She would like us to present this to the RN practice council at our hospital. I am wondering, do you use any guide, or know of research supporting when to refer, other than state requirements (i.e. LBW or drug exposed)?  I am very appreciative of your response in advance!  I really enjoy your Q and A series!!!

Sarah MOTR/L

Answer: See the guidelines in my 2007 article “An Evidence-based Approach to Nipple Feeding” available on my website. Recent papers by Jadcherla et al (2010), Kirk et al (2007) also profile what I like to call the “high-risk fragile feeder” that would benefit from support by therapy. You also should consider adding those infants who continue to require ventilation or HFNC when approaching 34 weeks PMA, as their respiratory co-morbidities are readily supported by both Kirk and Jadcherla’s findings. I am in the process of developing a 5 point scale to chart quality of feedings that should directly correlate with risk and need for therapy referral. Stay in touch!

Shaker, C.S. & Woida, A.M. (2007) An evidence-based approach to nipple feeding in a level III NICU: Nurse autonomy, developmental support and teamwork. Neonatal Network, 26:2, 77-83.

Jadcherla, S. R., Wang, M., Vijayapal, A. S., & Leuthner, S. R. (2010). Impact of prematurity and co-morbidities on feeding milestones in neonates: a retrospective study. Journal of Perinatology, 30(3), 201-208.
Kirk, A.T., Alder, S.C. and King, J.D. (2007) Cue-based oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants. Journal of Perinatology 27(9): 572-8.

I hope this is helpful.

Catherine

Q & A Time with Catherine…

Question:

I am working with a term infant just discharged home who is taking 40+ minutes to feed his bottle. He was referred by his pediatrician tour outpatient clinic since he is not gaining weight. Is this a normal time for newborns to feed? Can you help me think of what might be the issue?

Mary

Answer:
Hi Mary, 
the typical healthy newborn would not require 40 minutes to complete a bottle feeding.

While feeding times may vary from infant to infant or from feeding to feeding, the typical feeding time for a healthy newborn is 20-30 minutes. Some may indeed feed faster.

When the feeding time exceeds that average, for an infant without co-morbidities,  one might ask the question, what factors might be affecting efficiency? i.e. is nipple flow too fast and infant might be altering his sucking rate or pattern to limit flow? is the nipple shape not a good “fit” for the infant’s oral cavity? does the infant have a low hematocrit (blood count) that might affect endurance? is the infant jaundiced, which can affect drive/stamina? does the infant indeed have some subtle sucking or swallowing problem that is not readily apparent which might be affecting suck-swallow-breathe coordination? does the infant have GI symptoms during feeding that suggest GI discomfort as a reason for disengagement (i.e. stop-start behavior)? is the infant “working” hard during feeding (i.e. showing excessive breathing effort which can cause respiratory fatigue)? does the infant indeed have some subtle postural control or postural tone problems that may adversely affect stability and efficiency of motor patterns that underlie effective feeding? are there subtle oral-sensory issues? does the infant have state regulation problems that don’t support attaining a true quiet alert state shown to be optimal for feeding? what are the circumstances of the infant’s newborn history (prenatal, during delivery or after delivery) that might be playing a role, even though the infant is thought of as a “typical” newborn?

What else can you tell us about this infant so that we can help you problem-solve?

As I am thinking of possibilities to suggest to you as etiologies for this atypical feeding time, I am reminded of my good friend and colleague, Joan Arvedson, who said  “two important 4 letter words”  (LOL) are ……”What else?” , i.e. asking yourself as therapist “what else do I need to consider, what else do I  need to ask, what else might be helpful etc.”  Such wise words which I have never forgotten.

I find it’s asking the question that is most important, and you have :-) , and then asking more questions to help elucidate the answers, complete a differential. That problem-solving process is what makes our profession such a delight for me.

We look forward to hearing from you.

Catherine
Catherine Shaker, MS/CCC-SLP, BRS-S
Pediatric Speech-Language Pathologist
Board Recognized Specialist – Swallowing and Swallowing Disorders 
Windermere FL

http://www.Shaker4SwallowingandFeeding.com

Pediatric Swallow Studies: From Physiology to Analysis

I am excited to bring back my seminar on Pediatric Swallow Studies: From Physiology to Analysis this year! I get so many requests for information about not only how to interpret what we see during the swallow studies but also the hot topics that are unique to pediatrics, such as  thickening, nipples, frames per second, patient/family compliance.

I am amazed at the comments at the end of this seminar, from both adult therapists new to Pediatric video swallow studies, and from seasoned pediatric therapists as well.

I think the variety of videos that we watch really helps. Luckily I have captured over the years some great examples of more rare etiologies such as TEF, but also great demonstrations of the evolution of the pediatric swallow. The videos of preterms, then infants then toddlers then young children, help you to see the progression of the swallow. That is so fundamental to understanding what you see radiographically, what it means in the context of the developmental process, and then problem-solving what to recommend. Focusing on physiology and what leads to bolus mis-direction is the key.

You’ll have the chance to learn from those attending as well. I often learn something new or gain new insights from the discussions we have as a group, especially with the many case studies with their videos that we problem-solve.

Hope to see you this year!

Catherine

 

Want to enhance your problem-solving and skills with completing a differential for your pediatric feeding/swallowing patients?

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 2014! I’ll be teaching this seminar in Morristown, NJ (near NYC), Dallas, Irvine CA, Phoenix and lake Forest IL (near Chicago) 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 his caregivers.
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 26 years and continue to learn every day from the children we are fortunate to work with, and their families☺
We look forward to sharing our experiences and insights with you at Pediatric Swallowing and Feeding!!
Catherine and Theresa

Q & A Time: Providing cheek support in the NICU

Question: Providing cheek support in the NICU

If an infant has an inefficient suck because of lack of buccal fat pads and often slightly low tone the combination can result in too wide a jaw excursion and a very inefficient suck. Why would you not give jaw and cheek support (as needed) to make the whole coordination process easier and less fatiguing? If the baby’s resulting suck then is strong enough to receive too fast a flow, I would think that the solution would be to use a nipple with a slower flow rate, not eliminate the support that improved the suck. If nurses are giving too much support, it would also help to provide the training to create guidelines for the amount of support that is just right for each infant.

Answer
With all of our NICU babies, the value or adverse effect of strategies requires consideration of a number of underlying and related issues. One must consider the whole infant, i.e. co-morbidities (respiratory, airway, sensory-motor, and GI) when looking at supportive/compensatory techniques for feeding/swallowing.

Sucking pads are believed to develop in the last month of intrauterine life, so approximately 36 weeks in utero. So they are not available to many preterms. In normal postural/oral-motor development, the cheeks and lips are not active (i.e. not used) for feeding in the normal newborn until he is 3-4 months of life. Prior to that time, the cheeks/lips (they work as a system) posture on the nipple/breast for stability–they do not actively form an anterior seal to obtain the fluid bolus. As a result, the nutritive suck is achieved through a strong “tongue-palate” seal. I have seen a couple newborns and preterms with, unfortunately, multiple hemangiomas that eroded the cheeks and lips right after birth; each was able to feed effectively (no cheek support needed) due to an intact tongue and palate, and, therefore, a tongue-palate seal.

Even with a slow flow/controlled flow nipple, our vulnerable preterms can get too much flow, too large a bolus. When we add cheek support, we will increase the flow rate and the bolus size. Because most preterms have very strong sucks, often too strong for their own good, and are “stuck in sucking” much of the time, as Pamela Lemons wrote, caregivers must look at the dynamic, or synactive, impact of all interventions on each other. So if cheek support is used, it affects more than the suck, in other words. Increasing the flow rate, or doing so inadvertently through cheek support, is not supportive for preterms’ swallowing safety. While it will increase intake (efficiency of feeding), it is likely to result in physiologic instability. This may or may not be apparent as aspiration events in preterms are most often silent in my clinical experience. The anatomy of the preterm and the physiology of the swallow predispose the infant to easily overfill the valleculae; this, combined with a tendency toward increased work of breathing and an increased respiratory rate, along with neuromotor and neurologic immaturity, can render the airway unsafe. The preterm is unlikely to be able to make the dynamic adjustments required as the pharynx reconfigures itself from a respiratory tract to an alimentary tract and back to a respiratory tract with each swallow, especially if it occurs in the presence of flow that may readily move to a rate beyond his capacity.

We can provide the postural stability to offset lack of sucking pads through effective swaddling with limbs to the body midline, elbows inside the blanket, a sidelying position, neutral head neck flexion with slight tilting down of the chin, and offer effective external pacing based on the infant’s continuous feedback to help suck, swallow and breathing remain coupled and synchronous.

Over the last 25+ years working in Level III NICUs, I have rarely needed cheek support to facilitate safe and effective feeding; those occasions have been with sick newborns, not preterms.

I have also observed preterms offered cheek support during a Video Swallow Study (to assess its impact on the swallow, as it was being used at bedside by well-intentioned caregivers), overfill the valleculae and penetrate or aspirate as a result. Matthews wrote years ago that, with preterms, it is not the work of “sucking” that makes feeding challenging but the work of trying to “breathe” in the presence of a flow they cannot manage safely, which in turn then inhibits/disrupts breathing.

If volume is the overriding goal, cheek support may be viewed as a critical tool by some caregivers, and often unfortunately is. As there is hopefully a paradigm shift from “Volume Driven” to “Infant Driven” feeding in NICUs, the reasoning behind not using cheek support for preterms will hopefully be more readily understood by our nursing colleagues. Until then, helping our nursing colleagues understand the “why” behind our protective strategies, and the why behind strategies that are not viewed as supportive, is a good interim step.

Looking ahead to 2014!

Looking ahead to 2014!
Hard to believe it is almost Thanksgiving! I am taking a break to enjoy the Florida Fall and my German Shepherds who are ten and are the loves of my life. They get so excited when they, not my computer, have my attention, and get to go for a run in the Florida sunshine! My work at the children’s hospital continues to be so rewarding and another way for me to learn something new each day. I am amazed as well at what I learn from those of you out there who come to my seminars. I am inspired every day and am blessed with wonderful opportunities to grow.
It has been a busy year for me, with speaking across the US, and writing 4 manuscripts for publication! You can find my recent publications on my website. I am so pleased to hear from NICU nurses across the country and even internationally who have read my publications and written me to say how much the information I shared informed their practice and made a difference for the infants they care for. That is so rewarding to me!
Watch in mid-November for my latest publication, “Cue-Based feeding in the NICU: Using the Infant’s Communication as a Guide” which is being published by Neonatal Network, a wonderful neonatal nursing journal. I think it is my best work yet ☺ as it captures the critical dynamic nature of feeding preterms and how an infant-guided approach is essential. Let me know what you think!
Check out my 2014 seminar plan on the TAB on my website at the top “2014 Schedule”. My finalized 2014 brochure will be out shortly.
As we get closer to Thanksgiving, it’s a time to slow down and count our blessings. Thank you for staying in touch and for sharing your good thoughts about my seminars. Wishing all of you a wonderful season ahead and God’s blessings throughout 2014!
Catherine

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

Q & A Time: Problem-Solving with Catherine

Question: I am seeing an born 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.

Answer:

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 sidelying 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 trialed 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.

Announcing 2014 Seminar Schedule

2014 Shaker Seminars Brochure

Look for my acclaimed series of seminars…and a new one for 2014!

*Pediatric Swallowing and Feeding: The Essentials

*NICU Swallowing and Feeding: In the Nursery and After D/C

*Pediatric Video Swallow Studies: Physiology to Analysis

*Tracheostomy and Swallowing: Pediatrics to Adult

*Early feeding Skills Assessment Tool: A Guide to Cue-based Feeding in the NICU

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 bring your cases to solve. Come prepared to take it to the next level!

May 15-19: Morristown, NJ

June 13-17: Leesburg, VA * Tracheostomy, VFSS and Early

Feeding Skills Assessment Tool/Cue-Based feeding seminars!

July 11-15: Dallas, TX *includes new Advanced Clinician Seminar!

August 16-20: Irvine, CA

Sept 10-14: Phoenix, AZ

October 16-20: Lake Forest, IL

Q & A Time: Problems-Solving with Catherine

Question: This week I had a baby who was only 34 wks, 1 day (born at 29 wks) and doctors were pushing PO feeding and discharge (because I have a magic wand that can get a baby feeding in 24 hrs- sarcasm noted :). With a slow flow nipple, pacing to 3, and inclined/sidelying position, the baby had 3 episodes of desaturations and one episode of bradycardia. So, I talked with the doctors about trying the Bionix Controlled Flow nipple. I have used it 2 consecutive days, and baby’s intake was 6 cc’s on the first day with advancement to setting “2″ and 11 cc’s on the second day, with advancement of setting “3″. No more episodes of bradycardia/desaturations. Pt does have some stress noted as I advance settings, but I normally will stop advancing if pt shows signs of stress and he has seemed to tolerate it as we keep going. I’ve also implement pacing to help.
My question was, what types of patients benefit best from using these bottles? It seems as if it’s a good way to work on swallowing on the young babies (34-35 wks) without going quickly to a MBSS and giving them time to grow. If pt was 36+wks I would be quicker to move towards a MBSS, but bc of his age, I kind of want to give him time and practice before I radiate him so young. Does that line of thinking make sense? This is only my 2nd time using the bottle and it seems to be working well- giving the baby practice every day without overloading him. Any other specific cases in which this bottle worked well? Thanks in advance for your input! Sorry such a long post!

Answer: You don’t mention much about his history except that he was a 29 week GA infant. As a former 29 weeker, this infant likely has respiratory co-morbidities. I suspect he is in RA as you don’t mention any NC02. Not sure how early your NICU typically discharges but for a 29 weeker, discharging at 34-35 weeks PMA is not typical; an infant with his history is unlikely to be even a marginally-skilled feeder by that post menstrual age (PMA). He likely needs careful co-regulated pacing to support coordinated swallows.

It is true that swaddled sidelying and limiting the bolus size are  key interventions with preterms, as is using a slow/controllable flow rate.

A couple thoughts for you.

The external pacing you report providing with the slow flow nipple every 3 sucks may not have been a match for his needs. What I think of as providing  “pacing” is to  impose breaks from sucking to facilitate a pause in sucking, to allow for swallowing without delay, and then support the immediate initiation of several deep breaths. If the caregiver arbitrarily imposes a break in sucking at predetermined junctures, i.e. every 3 sucks, we take the infant’s communication from moment to moment out of the equation. The infants communication tells the caregiver when to impose a break, That is why I like the term “co-regulated pacing”–that means the infant and the caregiver have a reciprocity during feeding such that one guides the other. For a description of  the communication signals the infant uses to guide the feeder, you can look at the ASHA Leader February edition 2013 for the article I wrote entitled “Reading the Feeding”  in the NICU. You can also find it on my website www.Shaker4SwallowingandFeeding.com under the TAB “publications”. If we use the infant’s communication to guide the pacing, you then don’t arbitrarily pace at 3-5 sucks for example. You support the infant from moment to moment. So maybe with a slow flow nipple, i.e. Enfamil’s, you might see he showed you cues after one suck or two sucks; if so, waiting until 3 sucks may have given him a bolus that was too large, or that delayed the re-initiation of breathing too long, and caused swallowing and breathing to become uncoupled.

The Bionix bottle/nipple can also limit bolus size but I find the design of the nipple is not developmentally-supportive for the oral-sensory-motor system of the preterm. While its shape is consistent with what the evidence-base suggest is optimal, the hard tubing running down the center of the nipple (which is necessary to regulate flow in Bionix design) provides an atypical stimulus for the tongue, not like the breast certainly (which is soft and moldable during breastfeeding) and not like a typical bottle nipple (which can be compressed with no “hard” input).

For preemies, who already are in an altered sensory environment and are wiring their brains outside the uterus, we must all be thoughtful about any sensory input we provide/offer. Every experience matters in the NICU, especially with feeding. So I encourage you to look at Reading the Feeding, go back to the slow flow nipple and use all the other good interventions you mentioned. Watch the baby; let him guide you about what he needs and co-regulate the feeding. You don’t need the Bionix bottle in my experience.

I agree that going to radiology is not the next step given what you have told us.
I hope this is helpful

Catherine
Catherine S. Shaker, MS/CCC-SLP, BRS-S
Orlando, FL
http://www.Shaker4SwallowingandFeeding.com

Hi!

This week I had a baby who was only 34 wks, 1 day (born at 29 wks) and doctors were pushing PO feeding and discharge (because I have a magic wand that can get a baby feeding in 24 hrs- sarcasm noted :). With a slow flow nipple, pacing to 3, and inclined/sidelying position, the baby had 3 episodes of desaturations and one episode of bradycardia. So, I talked with the doctors about trying the Bionix Controlled Flow nipple. I have used it 2 consecutive days, and baby’s intake was 6 cc’s on the first day with advancement to setting “2″ and 11 cc’s on the second day, with advancement of setting “3″. No more episodes of bradycardia/desaturations. Pt does have some stress noted as I advance settings, but I normally will stop advancing if pt shows signs of stress and he has seemed to tolerate it as we keep going. I’ve also implement pacing to help.
My question was, what types of patients benefit best from using these bottles? It seems as if it’s a good way to work on swallowing on the young babies (34-35 wks) without going quickly to a MBSS and giving them time to grow. If pt was 36+wks I would be quicker to move towards a MBSS, but bc of his age, I kind of want to give him time and practice before I radiate him so young. Does that line of thinking make sense? This is only my 2nd time using the bottle and it seems to be working well- giving the baby practice everyday without overloading him. Any other specific cases in which this bottle worked well? Thanks in advance for your input! Sorry such a long post!
——————————————-
Mandi Hatfield
Augusta GA
——————————————-

Q & A TIme” Problem-Solving with Catherine

Q & A Time: Problem Solving with Catherine

Infants of diabetic mothers in the NICU

Question: It seems as if our NICU has had an influx lately of infants whose mothers were diabetic. I have found these babies to be very poor feeders. I am sure those of you who work in the NICU have had these babies also. I want to get some feedback from my colleagues about treatment techniques with these infants. Besides pacing and using slow flow nipples are there any other techniques you use with these babies?

Answer:  I agree that Infants of Diabetic Mothers (IDMs) are a challenging population. Due to the high sugar environment in utero, their blood sugars are initially off, and as a result they are very sleepy. Poor state regulation with the resulting inability to sustain alertness and drive/stamina for feeding is common; as their sugars normalize, we expect their state regulation to begin to normalize. They often also have increased WOB and intermittent tachypnea. This not only affects safety of suck-swallow-breathe coordination, but also stamina secondary to respiratory fatigue. Unfortunately, these infants are often term or near term, though not always. They can look “bigger” though they are often a bit low tone, most often described as being “doughy” as this is not typically true hypotonia  (i.e., with a neurological etiology) but can be more transient. That said, if an IDM makes slow progress in feeding skills, neonatologists will often study the infant’s head, as these infants are at high risk for brain malformations due to the intrauterine environment.

Most helpful interventions include: alerting techniques, re-alerting when infant becomes passive (so he is active with the feeding); avoiding any prodding or passive manipulation of the nipple/bottle/infant’s cheek or jaw–these interventions increase flow passively and can create safety issues and lead to feeding refusals; swaddling securely in flexion for feeding, supporting all limbs to body midline, hands near face–and re-swaddling after alerting infant versus feeding him “unswaddled”; use of a slow flow nipple to optimize swallow-breathe coordination–avoiding medium and high flow nipples that empty the bottle but are not supportive of coordinated feeding; I tend to not use chin/cheek support, as it increases flow rate and bolus size, which is often problematic if there is truly low tone. Also helpful is co-regulated pacing based on the infant’s continuous feedback regarding swallow-breathe timing and physiologic stability; concentrating the formula to increase caloric density so infant does not have to take as much volume while he is learning; respecting the infant’s signs of disengagement and not steering them back to sucking when they disengage; providing thoughtful and consistent anticipatory guidance and guided participation for all caregivers and especially families so they can understand and support the infant’s developmental strivings and emerging skills.

The biggest challenge as I see it with these infants in the NICU is getting everyone on the same page so we all let the infant guide us, via his communication, versus doing whatever is necessary to empty the bottle.