Shaker Seminars 2019: Latest Schedule Updates

Catherine Shaker Seminars – 2019

Brochure with course details and registration information will be available soon.

 

May 2019: Wilmington DE – Nemours Children’s Hospital

  • May 17-18: Pediatric Swallowing and Feeding: The Essentials
  • May 19: Pediatric Videoswallow Studies
  • May 20-21: NICU Swallowing and Feeding and After Discharge

June or November 2019: to be announced soon

July 2019: Columbia SC – Palmetto Children’s Hospital

  • July 17: Pediatric Videoswallow Studies
  • July 18-19: Pediatric Swallowing and Feeding: The Essential
  • July 20-21: NICU Swallowing and Feeding and After Discharge

August 2019: Indianapolis, IN    Eskenazi Hospital

  • August 16-17: Pediatric Swallowing and Feeding: The Essentials
  • August 18: Advanced Pediatric Dysphagia Pediatric Videoswallow Studies
  • August 19: Pediatric Videoswallow Studies 

September 2019: Plano/Dallas area, TX   Children’s Medical Center Plano

  • Sept 12-13: Pediatric Swallowing and Feeding: The Essentials
  • Sept 14: Advanced Pediatric Dysphagia
  • Sept 15-16: NICU Swallowing and Feeding and After Discharge 

October 2019   Columbus, OH   Nationwide Children’s Hospital

  • October 10-11 Cue-Based Feeding
  • October 12-13 Pediatric Swallowing and Feeding: The Essentials
  • October 14: Pediatric Videoswallow Studies

 

 

Problem-Solving: VFSS with former 24 weeker and thickening feedings

Question:

I have a question re: thickening formula in NICU. We don’t do vfss until >40 wks and no other compensations improve bedside feed.

We have a GA 24.6 wks; now 46.3 wks. Failed RA trial yesterday after 5 days of NPO/gavage only after a VFSS that documented laryngeal penetration and aspiration with slow flow in sidelying and upright with thin and nectar thick consistencies, so now NC 1/8L at 100%. Previously was bradying1-2x in a feed, so finally approved for the vfss…and while NPO limited to one Brady or desat a day. Vfss looked best with no penetration or aspiration with honey thick/IDDSI moderately thick. Would you agree with thickening of this infant to work towards safe feeds to go home with NCO2?

Answer:

What is the etiology for the aspiration events? To problem-solve, one must understand the physiology that underlies the bolus mis-direction you observed during the VFSS.

Is possibly GER/EER a part of the differential, as some events when not with PO feeding? Wonder about the effect of EER on laryngeal/tracheal sensation. Guessing that as a 24 weeker CLD may be a factor so both EER and poor swallow -breathe interface are key considerations.

Thickening is, as you know,  a last resort when other interventions are not establishing a safe swallow. Honey thick is rarely being used, both in my experience and as I ask other therapists form across the US and other countries, when I teach my seminars. Honey thick is worrisome in that if the infant requires something so thick to establish a safe swallow “in the moment”, he could during the course of a feeding have a change in position, a change in state, a change in bolus size, a change in sucking strength, a change in breathing pattern) that could easily result in airway invasion. Further, aspiration of honey thick in the developing lung of a former preterm with CLD can create undue pulmonary issues for which the risk-benefit ratio may be quite precarious.

Asking this infant to PO feed and go home a full Po feeder may in the longterm not be a good plan for him, his neuroprotection, his joy in eating and his pulmonary health. Based on what I know about him, which is limited (? other complex co-morbidities than respiratory?), I’d advocate for a GTube and offer readiness interventions (including cautious therapeutic pacifier dips)  to maintain his oral-sensory-motor system for safe return to PO feeing when co-morbidities permit. Often these are infants who, after 1-2 months post discharge, come for a repeat study, and  have established improved respiratory function that allows for the beginning of some safe PO feeding.

I hope this is helpful.

Problem-Solving: Benefits of sidelying for infants and maintaining readiness for safe return to PO feeding

Question:

I have completed two VFSSs for infants (1-2 months corrected age) in elevated side lying position who then went on to have FEES completed at a larger children’s hospital. The FEES were completed in upright position. The VFSSs I completed demonstrated functional physiology and no penetration/aspiration; however, the  FEES reports I received documented aspiration and recommended NPO x 3 months. 

 My concerns are the FEES are being completed in a position that the infants aren’t typically being fed in (the literature searches I’ve completed haven’t shown that upright is better).  Parents have also reported to me after the fact that the infants were crying throughout the completion of the FEES.  Lastly, I do have questions about the length of NPO recommendation (e.g. not building on oral feeding skills/experiences for three months and then expecting infants to learn them after the time frame when feeding is driven by reflexes).  As you can imagine, having conflicting results has been tricky to navigate. 

I am interested in your thoughts on an upright feeding position versus side lying feeding position during  instrumental assessment (for Infants under 3-4 months of age).  Any advice you would be willing to share regarding the above scenario would be greatly appreciated as well!

Answer:

Clinically I have consistently found that sidelying is more protective for swallowing and breathing, improves bolus control, and airway protection d/t muscular and gravitational impacts.

This is the most recent published paper/study by colleagues of mine:  Park, J., Pados, B. F., & Thoyre, S. M. (2018). Systematic Review: What Is the Evidence for the Side-Lying Position for Feeding Preterm Infants?. Advances in Neonatal Care, 18(4), 285-294.

FEES is clearly a valuable tool in swallowing diagnostics. Crying during FEES could, however, possibly  adversely affect the swallow-breathe interface, and therefore potentially contribute to an artifact that could alter physiology and lead to inadvertent airway compromise.

When an infant cannot PO feed d/t impaired physiology, we must still maintain the oral-sensory-motor system for future PO feeding. This includes non-nutritive oral-sensory-motor experiences which build components of oral-sensory-motor control combined with those components of motor control that underlie feeding function. Maintaining readiness often includes: offering tiny droplets of EBM preferably, or formula, on a pacifier or on the infant’s hands, or a trace dip of puree on a spoon. These offerings of create sensory load for purposeful swallows that stimulate fast twitch fibers.

This may of course carry some inherent risk, so one must carefully balance the risk for each infant with the benefits for long-term motor learning. Each infant must be considered in the context of his co-morbidities, developmental trajectory and day to day medical stability.

This cannot be approached as a cookbook but rather requires critical reflective thinking and clinical problem-solving to balance protection with learning. These experiences should be done after good oral cares, after postural stability is provided, and when the infant is at his best in terms of RR/WOB, state, postural organization, GI function etc.

The goal is to avoid loss of the multi-system integrated underpinnings for swallow function, avoid onset of disuse atrophy in a developing mechanism, and keep the emerging systems ready for future function.

I hope this is helpful