Join us for The Early Feeding Skills Assessment Tool: A Guide to Cue-based Feeding

Please plan to join Dr. Suzanne Thoyre and I on October 12-13th,  2019 in Columbus OH at Nationwide Children’s Hospital for a Train-the-Trainer session on  The Early Feeding Skills (EFS) Assessment Tool: A Guide to Cue-Based feeding in the NICU . 

Bring yourself, your colleagues, or your whole feeding team! We are aiming for an interdisciplinary-professional group, putting our heads together to improve feeding experiences for our most vulnerable infants. We hope to see you in Columbus! 

Learn to use the EFS to effectively plan and provide an infant-guided approach to feeding.

Simultaneously learn to train others back home to use the EFS to strengthen your unit’s feeding care. Review current research, the role of experience, dynamic systems theory, and feeding outcomes after NICU. Videotapes with enhanced audio of swallowing and breathing to learn key skill areas of the EFS: respiratory regulation, oral motor and swallowing function, physiologic stability, engagement, and change in coordination patterns of s-s-b as infants develop. Gain confidence scoring early feeding skills as not yet evident, emerging or established. Learn components of an infant-guided, co-regulated approach to feeding and contingent adaptations that make this approach so effective, using the EFS to plan individualized interventions. Receive teaching resources to take back to your unit to train others to use the EFS. As a group, we will network and navigate challenging issues and role-model a collaborative feeding practice.

The EFS provides a means of identifying, for individual preterm infants, areas of strength and areas in which support is required to accomplish safe and effective feeding. All too often during oral feeding, infants experience multiple episodes of oxygen desaturation, increased energy expended in response to stress, and fatigue. Possible negative sequelae of recurring stress are often unnoticed, disregarded, or minimized. Through developmental conceptualization of specific infant feeding skills, the EFS provides an infant-focused framework for planning individualized interventions.In addition, the EFS provides a means for assessing infant readiness to engage in oral feeding and for evaluating infant response to a feeding, including any interventions employed.

Assessment and intervention are integrated functions. As infants are fed and their capacities assessed, caregiver behaviors and assessment foci must be adjusted for the individual infant. If he stops sucking spontaneously only on occasion, for example, the infant probably needs a brief imposed break from sucking to support regulation of breathing and to prevent fatigue and/or physiologic dysregulation. If the infant does not root when his lips are stroked, indicating lack of readiness to feed, the feeder explores reasons for this. If the infant has difficulty coordinating swallowing and breathing, the feeder is more alert to his capacity to manage the bolus of fluid given the frequency of sucks and the duration of sucking bursts. The feeder will want to help prevent abbreviated or missed breaths for the infant, to listen more closely for complete and safe swallowing, and to explore the need for a sidelying feeding position, low-flow nipples, pacing strategies, or more extensive swallowing evaluation by a pediatric therapist. Thorough and ongoing assessment is an essential component of feeding practice, particularly for infants early in their skill development. 

Not only does the EFS provide a pathway for your NICU team to infant-guide feeding , but it also has been shown to have strong psychometric properties for use in research. See:  Thoyre, S. M., Pados, B. F., Shaker, C. S., Fuller, K., & Park, J. (2018). Psychometric Properties of the Early Feeding Skills Assessment Tool. Advances in Neonatal Care, 18(5), E13-E23.




Research Corner: The Need for Psychometrically Validated Feeding Assessments in the NICU

Does the Infant-Driven Feeding Method Positively Impact Preterm Infant Feeding

Outcomes? Margaret Settle, PhD, RN, NE-BC; Kim Francis, PhD, RN, PHCNS-BC

Settle, M., & Francis, K. (2019). Does the Infant-Driven Feeding Method Positively Impact Preterm Infant Feeding Outcomes?. Advances in neonatal care: official journal of the National Association of Neonatal Nurses, 19(1), 51-55.


Background: Achievement of independent oral feeding is a major determinant of discharge and contributes to long lengths of stay. Accumulating evidence suggests that there is great variation between and within newborn intensive care units in the initiation and advancement of oral feeding. The Infant-Driven Feeding (IDF) method is composed of 3 behav­ioral assessments including feeding readiness, quality of feeding, and caregiver support. Each assessment includes 5 categories and is intended as a method of communication among caregivers regarding the infant’s

Findings: There were no randomized control, quasi-experimental, or retrospective studies utilizing the IDF method. There were 3 quality improvement projects utilizing the IDF method. The findings were conflicting: 1 project found the IDF method favorable in the achievement of full oral feedings, 2 projects found the IDF method favorable for reducing length of stay, and 1 project did not find differences in initiation, achievement of oral feedings, or length of stay.

Implications for Research: Research is needed to empirically validate the IDF method and to inform practice related to the initiation and advancement of oral feeding for preterm infants.

Commentary from  Catherine:  

The discussion section in the article states” Emerging evidence suggests that consistent oral feeding assessments may improve the preterm infant’s progression from gavage to full oral feeding and reduce the LOS. However, there is a lack of psychometrically tested feeding assessment tools. A comprehensive feeding assessment method that is psychometrically validated is needed to facilitate feeding progression for preterm infants.”

The Early Feeding Skills Assessment Tool developed by Thoyre , Shaker and Pridham is such a tool.

See: Thoyre, S. M., Pados, B. F., Shaker, C. S., Fuller, K., & Park, J. (2018). Psychometric Properties of the Early Feeding Skills Assessment Tool. Advances in Neonatal Care, 18(5), E13-E23.  See information on this publication in my June 2018 posts here on my website


Research Corner: Pediatric Feeding Disorder Consensus Statement

Check out the consensus paper in the January issue of the Journal of Pediatric Gastroenterology and Nutrition!   Click on the link below.

Facilitated by Feeding Matters and written by an international panel of 18 pediatric feeding experts, “Pediatric Feeding Disorder — Consensus Definition and Conceptual Framework” defines pediatric feeding disorder (PFD) as impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction.

By incorporating associated functional limitations, the proposed diagnostic criteria for PFD should enable the healthcare community to better characterize the needs of this diverse population of patients; facilitate collaborative care among the relevant disciplines; and promote the use of common, precise, terminology necessary to advance clinical practice, research, and health-care policy.

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


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?


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


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!


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