Problem-Solving: Infants with HIE in NICU

Question from SLP:

The LC (from a nursing background) and I don’t seem to agree. Particularly with an grade 2 HIE infant we weren’t in agreement but it I think it is applicable beyond. For complex or fragile infants learning to breast feed, when they begin falling into the sleep state and reflexively sucking but holding onto the nipple would you tend to a) break the latch and discontinue the feed? Or b) would you do this after a certain amount of time – eg 45 minutes to an hour after waking the infant or c) let them go until they let go of the nipple.Thanks for your help,

Catherine’s Answer:

Can you tell us more about the infants skills, course and history? Altered state regulation for goal directed behavior for feeding is worrisome in the setting of HIE, to which you allude. It may predispose some infants post HIE to silent aspiration, if indeed swallowing and oral-motor integrity are altered. This is often the case with HIE, depending on the bigger picture of co-morbidities,  neurologic data/MRI, WOB and postural/sensory-motor integrity, and how their developmental trajectory is emerging post event. Quiet alert state in this population is typically critical for safe feeding and for actively learning and establishing neural motor maps for safe feeding. What impact do tactile/vestibular re-alerting techniques, f/b secure swaddling to promote postural stability and alignment have?

Response from SLP:

So the main question is whether you allow neonates for keep sucking at the breast when they are not in a quiet alert or even drowsy state. The LC does not think it’s appropriate to cut off a breast feed unless the infant is overtly not tolerating. And she would I say if they still are holding onto the nipple they are still engaged in the feed. The particular infant we were disagreeing about was cooled 72 hrs, seizures initially, rescued tone, suck present but initially weak. He was only 1 day post rewarming when the LC and I assessed jointly. He struggled to rouse for the feed but following cares and some non-nutritive sucking on the pacifier, he was offered the breast – demonstrated active rooting and immediate initiation of strong sucking. He changed sides and again strong root and suck. A few audible swallows but not much as milk supply was limited. When he fell more into a drowsy and then light sleep I thought we should remove him from the breast, especially as it had been nearly an hour since they had first started trying to wake him. But she disagreed and it created a very awkward situation in front of a parent and one that we have gone round and round on since without agreeing. Just finding my therapy lens and her lactation lens are not seeing the same thing or able to come to an agreement.

Catherine’s response:

It is challenging to answer regarding all neonates, as not all neonates, as you know, are the same. There isn’t of course a one size fits all answer, which you recognize but she may not. The co-morbidities you describe are, for me, a critical part of problem-solving how to proceed during a breastfeeding session for this particular infant .

For this infant, in the setting of his co-morbidities, I would not allow him to suck “on automatic pilot” the way that mothers of healthy infants might. Healthy infants without co-morbidities, like LC might see in NB nursery, will still learn when breastfeeding in drowsy or light sleep state and are typically quite safe. The healthy NB might rest without fully maintaining latch and then re-engage smoothly when hunger provokes return of drive.

This is very different than the situation for the infant you describe. Having required cooling/therapeutic hypothermia for 72 hours, with altered postural and oral/facial tone (likely leading to the weak suck) is at high risk for airway invasion. Most infants with his history and a weak suck also have alterations in their swallowing integrity because the neural underpinnings for sucking and swallowing have overlapping function.

After an hour of efforts at breastfeeding, 1-day post-rewarming, his disengagement needs to be respected. The integrity of his likely already fragile swallow will be less reliable and less timely with the onset of fatigue. That is so different than a healthy NB. Perhaps focusing on his unique history and co-morbidities as the basis for your wanting to rest and protect him, as contrasted with acknowledgement of how you would agree that with a healthy NB the session would be different, would be a starting point for collegial conversation over coffee.

The lens through which she is looking at the skills he brings to his breastfeeding may not readily include full awareness of the adverse effects of HIE on those critical underpinnings as they relate to safety. But we recognize her good intentions. Continued dialogue is the key. You can offer a perspective that is probably different from hers and could “round out ” her perspective,  and reframe his behaviors with new meaning.

Question from another SLP in response:

We have a very similar infant in our level 3 NICU…36 weeks, HIE, cooled for 72 hours, seizure activity. He survived re-warming, does have white matter damage per MRI but no infarct. He is currently on a CPAP of 6 and tolerating for the most part although RR is often well over 70. With cares he does demonstrate some nice periods of quiet alertness, will bring his hands and fingers to his mouth, and suck on a pacifier. He does a lot of tongue thrusting.. perhaps related to the placement of the OG but also ? if there is more of a neurologic component . Mom also would like to breast feed although with other children at home I’m not sure he will be a sole breast feeder. He has a very wet productive sounding cough at times with cares which concerns me a little bit…question possibility of silent aspiration with own secretions. He has not started to PO yet given respiratory status but I’d love to have any insight into this situation as well. I am very concerned about the risk for aspiration. Being a level 3 NICU, many of our babies on cool cap end up being transferred to a level 4 NICU for higher level care so I just want to make sure we are taking all necessary precautions when this infant does start to PO feed. Thank you so much

Catherine’s response:

I agree that his current clinical presentation and history are worrisome for ability to be a safe PO feeder, given what we know right now. His risk for altered swallowing function seems quite high, and a wet cough at rest, increased WOB and intermittent tachypnea. I would suspect that the altered oral -motor integrity you describe is likely neuro-related as opposed to the presence of an OGT in situ, as  it is not a typically co-occurring variance with typical  late preterms without his neurologic co-morbidities . As respiratory support is weaned, and he has an opportunity to fully exhibit the range of behaviors (or lack thereof) prerequisite to PO feeding, you can help the parents learn along with you about the complexity of swallowing for late preterm infants,  prerequisites for PO, his skills and challenges given history ad know diagnoses/test results,  a focus on the little steps toward readiness to feed. As you build the  relationship of trust , you can come from a for a perspective of knowing they want the best for their infant; you can help mother learn along with you through your offering pacifier dips of mother’s milk for purposeful swallows and reflect to her what that suggests to you about suck-swallow-breathe function, before actual PO is on the horizon. You will be learning about him and so will she, so when the team considers an order for nuzzling at breast, a foundation of teamwork and mutual problem-solving will have been established. That will be a good place from  which to have continued conversations.

Problem-Solving: Fluoro Time for Neonates


At the hospitals that I work at we have outdated machines that only capture video swallow studies at 6 frames per second. Are the restrictions the same for fluoro time (I think it’s about 2 min recommended fluoro time at 30 frames per second for peds and neos)?

Catherine’s Answer:

The low frame rate will of course limit the objectification of swallowing physiology, unfortunately, and sometimes can lead to the need for increased exposure time. Multiple citations by Heather Bonilha Shaw would be helpful as you advocate, along with your radiologists, for equipment that provides 30 fps.  Given your situation, ALARA (as low as reasonably achievable) should remain your guide. That said, as I teach across the US and survey attends at my swallow study seminars, is most typical that with neonates, the aim is the least amount necessary but less than 2 minutes; with pediatric patients, less than 5 minutes. Of course, co-morbidities, compliance, previous exposure to x-ray/radiation, and clinical impressions about physiology as your go along in the study, all must be considered.

Our tech tracks the exposure time as we go along, the rad and I are very aware, and at each juncture I am asking myself “have I objectified physiology sufficiently? Do I need more time?” and if so I am very thoughtful about continuing or not. if I need a few more swallows to better elucidate physiology or complete a differential, or to objectify the likely positive impact of an intervention, I usually discuss it with the rad and we agree on further time based on a determined required need. Most infant studies are less than 2 minutes exposure and most of our pediatric patients less than 3 minutes, at 30 fps.

At the end of each study, I think always ask myself, ” is there anything I could have done differently to reduce exposure time?” Maybe not but it keeps my always trying to do better for my little patients. Heather is on the ASHA list serve, and, I am sure, can add her always appreciated thoughts. Her recent commentary (see list serve archives) on a paper suggesting 15 fps in pediatrics so eloquently explained issues even in 15 fps for our population that may also be useful in helping to make the case for equipment that provides 30 fps.

Problem-Solving: Respiratory rates in neonates

Hot topic and in need of evidence based research regarding bottle feeding the premature infant (or term infant) with tachypnea.

What is everyone’s practice?  No PO feeding if respiratory rate above 60? 70?  Would appreciate research articles and your hospitals guidelines!

Catherine’s answer:

To my knowledge, there is no research to guide practice but rather the it is often neonatologist training,  preference and the extent to which intake is a key driver in a particular NICU. Neina Ferguson published an informative paper in 2015 about preterm infants in  the NICU that correlated tachypnea during PO with subsequent aspiration in radiology.

Ferguson, N. F., Estis, J., Evans, K., Dagenais, P. A., & VanHangehan, J. (2015). A retrospective examination of prandial aspiration in preterm infants. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(4), 162-174.

The paper did not look at impact on physiology in detail, but I clinically see in the NICU population that tachypnea can alter physiology without witnessed aspiration or penetration under fluoroscopy, and thereby create risk for airway invasion.

Some neos write orders to PO if infant is “comfortably tachypneic”, RR under 70.  “Comfortably tachypneic” is a almost parodical , in that tachypnea is rarely co-occurring with a comfortable looking infant, rather infants who are tachypneic may often be  exhibiting other signs of physiologic stress (e.g., nasal flaring/blanching, suprasternal and/or supraclavicular retractions, chin tugging). Increasing RR leads to more shallow insufficient respirations. The need to breathe often and rapidly will create challenges in the swallow-breathe interface, and cause breathing and swallowing to uncouple. It takes a second to complete the pharyngeal swallow, so then a RR over 60 clearly increases risk for airway invasion.

Respiratory Rate, my RT mentors tell me, doesn’t exist in isolation but is rather a part of a bigger picture. Much like, they say, level of respiratory support required does not exist in isolation. It’s each infant’s bigger picture that guides us.

As we advocate and make determinations of relative risk with PO feeding for our preterm infants, we really must look at each infant in the setting of his unique history and co-morbidities and their unique attendant sequelae. An infant post HIE just weaned or HHFNC will require a different algorithm than the former 24 weeker with CLD, contrasted with the term infant who is s/p TEF/EA repair. And, as Dr Coyle says, that is ok. One algorithm won’t work for every patient and it shouldn’t. All of my examples are infant who often have risks for airway invasion but the nuances of each infant will likely yield a slightly different profile from which to problem-solve, with the team.

That is the challenge of our work in the NICU. To look at each infant as a unique patient, and,  in the setting of what we know about him, and what we see clinically, make a well-thought out educated plan to minimize risk, articulate those risks as best we can to the team, establish interventions that optimize safety and assess their impact on an ongoing basis.

In the NICU , we are required to  live in the grey zone…no easy questions and there are no easy answers, more questions than answers, constantly thinking and re-thinking.  Just keep “listening” to each infant Tara, like you are doing, and especially partner with RTs and a neonatologist that respects the complexity of feeding and swallowing so they can think along with you.

Problem-Solving: Vocal Cord Paralysis and Sidelying


Does anyone know of any research articles regarding the effectiveness of putting an infant with a left vocal fold paralysis in a sidelying position for bottle feeds? Also, what are your thoughts about performing an MBS or FEES prior to initiation of PO feeds?


To my knowledge there are no randomized controlled trials or research studies regarding this intervention. The pediatric ENTs who took me under their wing early on in my career suggested it and theoretically it made sense to me. While its proposed purpose (, placing infant with a left vocal cord paralysis R side down for PO feeing) is to utilize gravity to assist by passively bringing the paralyzed cord to midline, it is unlikely that can simulate true effective closure as one would observe in the setting of normal vocal cord motility.

In addition, if there are other co-occurring co-morbidities that adversely affect airway, postural or swallowing function, those most also be considered in the differential. However, combined with other interventions such as controlling flow rate, co-regulated pacing and resting, we have consistently seen improved dynamic swallowing objectified under fluoroscopy in radiology. That clinical wisdom is a level of evidence base that has helped to guide my practice.

There is also a high risk for a paralyzed R vocal cord post ECMO, so many of our cardiac infants and select preterms who require ECMO. Similarly, I have both clinically and instrumentally observed a left side down position in the setting of a R vocal cord paralysis to be a useful intervention to trial.

Once again, need to consider all co-morbidities that maybe relevant to guide us. I prefer that infants not have their first PO feeding experience in radiology. It doesn’t allow me to complete a cautious limited clinical examination of PO feeding prior to the instrumental, during which time I can begin to formulate a differential regarding the full picture (i.e., potential effects of respiration, state, and other co-morbidities on the infant’s feeding/swallowing function in the context of the infant’s history. Also, during that first feeding, when sensory-motor maps are being established and recruited, they must be on the x-ray table or in an infant seat. That said, we recognize that high risk for airway invasion in the setting of both L and/or R vocal cord motility issues. If clinically indicated, I prefer at least 1-2 very small brief PO feeding experiences with me while I trial the interventions and allow the infant to experience sensory-motor learning under optimal conditions. This can be as little as 5 mls. Because we recognize that swallowing physiology needs to be objectified to guide management for such an infant, an instrumental assessment would then follow. FEES would clearly inform our differential, and a VFSS would provide insight into the dynamic swallow pathway. I hope this is helpful.

2020 Catherine Shaker Seminars: New Offering!

As the New Year approaches, I look forward to travelling across the US, meeting colleagues with a similar passion for “all things feeding and swallowing”. While I love teaching, I also love learning from the therapists I meet and making lasting friendships as well. We each have so much to share and I never stop learning .

I have added a new seminar for 2020: Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Challenges Two days of problem-solving designed just for you and your patients, NICU through school aged. We’ll discuss complex diagnoses, hot topics in dysphagia (for example: thickening, NMES, oral-motor “exercises”) and current practice issues such a team communication, managing challenging clinical situations, and navigating therapist-physician relationships in the intensive care unit. I look forward to learning along with you

Pediatric Swallowing and Feeding: The Essentials – 13 hours contact hours – 2 days Pediatric

Videofluoroscopic Swallow Studies: From Physiology to Analysis – 6.5 contact hours – 1 day

NICU Swallowing and Feeding: In the Nursery and After Discharge – 13.5 contact hours – 2 days

The Early Feeding Skills Assessment Tool: A Guide to Cue-Based Feeding in the NICU – 13 contact hours – 2 days

Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Challenges – 13 contact hours – 2 days


Nashville – May

Houston – June

Orange County CA – July

Chicago area – August

Phoenix – September

Greenwich CT – October

Watch for details soon on my website or sign up for my blog and you will receive automatic notice when my seminar schedule and brochure are posted in January.

Wishing you abundant blessings in the New Year ahead. I hope our paths cross in 2020!


Problem-Solving: Sensory Normalization with Rubinstein-Taybi Syndrome


I recently started treating a 2-year-old little girl with Rubinstein-Taybi syndrome in outpatient feeding therapy. She has had a G-tube since she was 1 month old and has barely eaten PO. I am just trying to get her to take PO to get her to a VFSS, as the last VFSS she had, she aspirated after the swallow due to residuals in pyriforms. No cough response at the time. She is literally so averse to even a dry spoon touching her lips, she tightens her lips and turns her head no matter how many times I do it in an attempt to desensitize her. The one time I touched a dipped spoon to her lips, she had a moderate-severe gag response. And the amount of vanilla pudding in the bowl of the spoon was so minimal, I couldn’t really lessen it….we just went back to a dry spoon. I’ve tried the Honey Bear straw, I’ve tried a spoon with cold water, Dum Dum lollipops….no luck. I’m really at a loss. We’ve had 4 sessions so far and no progress…and even possibly a regression, as she now won’t even sit in the high chair for more than 10 minutes without getting restless, reaching out, wanting to play and/or sit on parents laps. She has no verbal communication, only whining and reaching arms out. She can identify some things but it’s inconsistent. However, I know her receptive language and memory are her strengths. Any suggestions/feedback/advice is greatly appreciated! I need all the help I can get with this little one.


Normalizing her sensory-motor/postural system (through partnering with a sensory integration trained OT) and normalizing her oral-sensory system will be a critical first step. PO feeding skills are built on a well integrated sensory system, often a key area of need for children with this diagnosis.

A swallow study likely isn’t a next step for her until she is accepting well graded positive oral sensory input. There is likely some level of swallowing impairment that won’t be fully understood until the sensory system is normalized, which will allow her to then begin to accept trace tastes of purée to eventually support an instrumental assessment of swallowing physiology.

Her progress will be slow due to her underlying diagnosis and a sensory system that has been impaired since birth. These systems are complex, require heavy neuro underpinning and require new sensory- motor maps be created in the brain through child-guided well graded sensory motor learning. Co therapy with an OT focused on sensory treatment with SI intervention would be a great facilitator. Parents can learn along with you about the need to think of small steps “toward” eventual PO but that is not the immediate goal due to the many little steps of learning required before she is truly ready to eat/drink orally.

Problem-Solving: Former Preterm with Beckwith Wiedemann Syndrome


I have a 34 week premature infant with Atrial flutter and Atrial septal defect that I just started seeing who has Beckwith Wiedeman Syndrome. The pediatrician recommended solid food feedings due to not taking his formula consistently. Mom only gives him baby food at night and he eats about half a container but seems to enjoy it. He had a MBS since he was receiving thickened formula with oatmeal on 6/5/19. He was clear for thin liquids via Avent level 1. He got frustrated with nipple so SLP in outpatient ok’d him to use Avent level 2. According to his MBS, he had oral transport/lingual motion impairment and oral residue. His swallow response is impaired at level of pyriforms, laryngeal elevation and anterior hyoid excursion are also impaired. At rest, child’s tongue protrudes and when he sucks on the bottle and when spoon feedings are tried, he has a tongue thrust. Coughing is noted during bottle and spoon feedings and when the bottle is pulled out of his mouth every 2-3 sips to help him breathe, he seems to have difficulty latching onto the bottle. I’ve tried palpating gently under his chin and noticed his tongue recessed into his mouth for a brief time, and have tried a ‘j scoop’ with the spoon when fed him. I just wonder what other treatments you would recommend I try since his doctor wants to try therapy before surgical treatment of macroglossia.


Sounds like he is a former 34 weeker who you are following in the community. What is his adjusted age now?

Being a former preemie, as opposed to a former full term infant, adds some other challenges to his BWS that might be playing a role, such a respiratory co-morbidities. Sounds as though he was sent home from the NICU as a full oral feeder, but quality may not have been part of the assessment for readiness to be a full PO feeder, rather volume was.

What looks like tongue thrust may actually be the tongue moving forward with onset of motion, due to the lack of space in the oral cavity for his enlarged tongue as it moves posteriorly and an adaptive response on the part of the infant to maintain his upper airway.

Sounds like he was sent home without any respiratory support to assist with airway maintenance. Many infants with BWS require trachs to assure a consistent patent upper airway. Even so, some who manage to be discharged without airway support can readily destabilize a fragile upper airway with the act of swallowing during feeding. The need for the base of tongue to retract, and the large thickened blade to move posteriorly as part of the swallow, can actually “create” a sense of further airway obstruction with the act of swallowing. In addition, the thickened blade with intrinsic tongue muscles that lack thinning and cupping can create challenges with bolus control orally.

The macroglossia also can alter mandibular alignment, leading to subluxation. It also inhibits a closed mouth posture, which can work against establishing the necessary anterior seal on the bolus to help drive the swallow.

Often behaviors during feeding may be related to the struggle during feeding to manage the bolus and maintain the upper airway, and can lead to adaptive behaviors, which then create maladaptive feeding behaviors and long-term struggles with eating/drinking.

Sounds like with Avent 1 flow in radiology there was a delay in swallow initiation with premature entry to the pyriforms. It is likely the bolus is poorly managed due to the adverse effects of BWS noted above, so it would be important to objectify the effect of the change/increase in flow rate with Avent 2 on his swallowing physiology, as his physiology sounds precarious. The coughing with spoon and bottle suggest fluid has approached or entered his airway.

Even if he there was no witnessed aspiration or laryngeal penetration during the VFSS (which is a moment in time), he is at high risk for airway invasion and onset of aversions due to the struggle to feed. Most events of aspiration are silent in the infant population,  and he is also giving us some signs, so he is likely more worrisome.

I think the doctor’s well-intentioned goal of wanting him to PO feed before surgery may have been made without his understanding of the impact of BWS on swallowing physiology and the swallow-breathe interface, and may be counter productive and perhaps not safe for this former preemie. Muscular and structural restrictions such as those with BWS often require us to take a step back and look at the co-morbidities and their overriding influence on swallowing physiology not just on intake, which is at times challenging for our medical colleagues.

Problem-Solving: Late Preterm with Sequelae from Mandibular Hypoplasia


I am presently working with an 8 month old who is s/p cleft palate repair, x 1 month. She is an ex 35 weeker with a trach and PEG tube. Her list of problems/diagnoses: Pierre Robin Sequence, Peter’s anomaly, ASD, Stankiewitcz-Isidor Syndrome, retrognathia, and micrognathia. Currently, she eagerly accepts the pacifier and bottle. We are using Dr. Brown’s level 1 with the valve but this flow seems a little fast and are trying the Newborn level. However, her tongue pulls back and therefore is not wrapping around the nipple for traction. She gets approximately 10-15ml in 30 min only due to compression. Any time that I attempt to put a gloved finger on top of her tongue to work on drawing it forward she gags. At best she reluctantly allows my gloved finger with formula just to the tip of her tongue. Any recs? Also, what resources/books do you recommend for infants/children with cleft palate?


I think right now the cleft is the last important factor and is likely not contributing to what you are seeing with PO attempts. Her complex co-morbidities make a her a fragile feeder,  I would think, with high risk of silent airway invasion. The muscular and structural restrictions to the mandible, and therefore, to the tongue (glossoptosis) associated with the Pierre Robin and Peter’s Anomaly, likely lead to adaptive behaviors in an attempt to protect the airway. That then leads to the maladaptive behaviors you are seeing. My guess is her trach was placed  to establish an airway (not for long-term ventilation), so without a PMV (which she cannot wear due her airway obstruction), she also has no taste, no smell and has no subglottic pressure for airway protection. I would not PO with what I know, but rather, work on readiness non-nutritively right now. ENT would be very helpful  to guide your plan of care by assessing growth and readiness for decannulation in the future.

Problem-Solving: Initiating PO Feeding in the NICU


My colleagues and I have been discussing the age at which to start bottle feedings. I realize it will depend on the child’s development, their history, their stress level, and rooting behavior. But in writing a policy for the NICU for cue Based Feeding I was hoping for a starting age. We’ve said 33 weeks or greater. I have a NICU manager who is pushing for 32 weeks, and a neonatologist who wants to stay away from a defining age. Currently we have “CBF to begin 33 weeks or later. Any infant younger than 33 weeks to be assessed by speech therapist first.” But that last statement has yet to be approved. And I was hoping to have literature to back the age. Any feedback is much appreciated.


The question about when NICU infants initiate PO feeding is of course multi-factorial, so PMA (post-menstrual age) is just one factor. Unfortunately, while it puts us in “the ballpark”, it has little value in and of itself. The PMA has significance, I like to say, in the context of the infant’s co-morbidities and history. Considering only PMA without regard for co-morbidities and history can lead to first PO feedings that are physiologically stressful, adversely affect neuroprotection and set the stage for feeding early onset refusals as a result, as you know. Some infants at a particular age, for example, 37 weeks PMA may not be ready/appropriate to PO, often due to the sequalae from their co-morbidities and history.

As I teach across the US regarding NICU feeding/swallowing practice, the earliest I have heard PO feeding being initiated is 31 weeks PMA. This has typically been a healthy preterm stable on unassisted RA and with a clean history; but even then, readiness of requisite subsystems, such as postural/head/neck control and state modulation, may not be available for that infant, and the suck-swallow-breathe interface is likely quite precarious. Asking the infant to feed 9 weeks prior to his due date would be worrisome. The push to “get infants out” and the desire to “get infants home” has created undue pressure on the infants, staff and in-turn on families to “get it in”.

Perhaps that is why the neonatologist is suggesting avoiding a defining age and is looking instead, hopefully, at a more global assessment of the infant. Alternatively, he/she may be leaving the door open to push harder unfortunately . Carrie Anne’s reference should be helpful but unfortunately Dr. Pickler often has a focus on “practicing” PO as a benefit and the pathway to good outcomes. While some in the NICU think “practice makes perfect” when it comes to feeding, unfortunately, when feeding attempts are ill-timed or are not truly supportive, then “practice”  only makes “permanent”   the emotional overlay and activation of the HP axis/cortisol release associated with physiologic stress in preterms, that likely co-occurs with trying to feed and struggle. Contrast that with an infant-guided feeding approach , truly cue-based PO feeding, that focuses on the experience and neuroprotection, versus intake.

Individualized readiness using multiple factors, one of those factors being PMA, is ideal an most supportive of neuroprotection. I am not aware of any research that has specifically determined “the age” to start, as so many variables indeed must be taken into account as I referenced above. That would be a hard study to do and do well. My thought is that 33-34 weeks PMA is likely most typical across the US based on feedback I solicit in every city I teach. If you can help to build criteria that encompass not only age (PMA), but a more comprehensive look at the infant, then perhaps there will be room purposefully built in to individualize and assess that unique infant’s readiness in the setting of his co-morbidities and history.

Research Corner and Commentary about Article in the ASHA Leader on Thickening in the NICU

This is an excellent article just published by our colleagues at Boston Childrens and will inform your practice.

Duncan DR, Larson K, Rosen RL(2019) Clinical aspects of thickeners for pediatric gastroesophageal reflux and oropharyngeal dysphagia.
Current gastroenterology reports.

The purpose of this review is to discuss current knowledge and recent findings regarding clinical aspects of thickeners for pediatric gastroesophageal reflux and oropharyngeal dysphagia. We review evidence for thickener efficacy, discuss types of thickeners, practical considerations when using various thickeners, and risks and benefits of thickener use in pediatrics. Recent Findings: Thickeners are effective in decreasing regurgitation and improving swallowing mechanics and can often be used
empirically for the treatment of infants and young children. Adverse effects have been reported, but with careful consideration of
appropriate thickener types, desired thickening consistency, and follow-up in collaboration with feeding specialists, most patients have symptomatic improvements. Summary Thickeners are typically well tolerated and with few side effects, but close follow-up is needed to make sure patients tolerate thickeners and have adequate symptom improvement.

On a related note, I feel compelled to address a recent article in The ASHA Leader “From My Perspective: Overuse of Thickeners in the NICU.”

The article, I believe, while certainly written with the best of intentions, has the potential to set back the progress SLPs have made delineating a critical well-respected evidence-based role in the NICU and, left unaddressed, could do harm.

I am concerned that  SLPs (both adult and pediatric)  who are unfamiliar with the work of NICU SLPs may, after reading the above mentioned article in The ASHA Leader, have an inaccurate the impression about our practice. The article appears to make assumptions, and appears to question the clinical reasoning that underpins decisions made every day, with deliberate consideration for short and long-term implications and for best practice.

Many of the assumptions made by the author  are not consistent with both my practice in large level IV  NICUs for the last 35 years, nor the practice of most other NICU SLPs I have met as I teach across the US about NICU intervention. While there may indeed be variability in the knowledge and practice of some NICU providers (Madhoun, et al 2015),  the AAP recommends caution with thickeners in preterm infants, and this is typically the overriding consideration for all interventions prescribed in the NICU. First, do no harm. 

The author’s statement that “thickeners are a long-term solution” is not consistent with typical NICU practice. Thickeners are used only as the last resort in the NICU (Gosa, 2015) —- after trialing changing feeding position, slowing nipple flow rate, utilizing contingent  co-regulated pacing to support the swallow-breathe interface and assure timely and sufficient breaths.  Even then, thickening may not be the safest solution for a specific  infant and can  present untoward sequelae ( higher risk to aspirate after the swallow, concerns of digestive immaturity, malabsorption, NEC, etc.) Most NICUs rarely use thickeners today to the extent that they were used in the past, and if thickeners are, it is viewed as short term. In dialogue with the medical team, there is typically careful interdisciplinary deliberation of the risk benefit ratio. If indicated, there is typically the contingent use of interventions to minimize the risk, and support both oral-motor learning and motor learning, and avoid maladaptations that may result.

Each NICU infant’s  developmental progression, respiratory, GI and neuro history and co-morbidities must be considered, as well as the nature of the pathophysiology objectified in radiology.  When the author states that “failing a swallow study” is a reason to thicken, it suggests the author considers a swallow study as a “pass-fail procedure”.  Rather than a pass-fail procedure, an instrumental assessment is viewed with the NICU population, as an analysis of swallowing physiology, its alteration or impairment, and its implications for that unique infant in the setting of his unique presentation/data set.  Like with other populations for whom SLPs provide services, a neonate does not need to penetrate or aspirate to have a swallowing impairment that may lead to airway invasion. As a result, the level of analysis that is required, and the essential caution as to prescribed interventions, is well understood by those of us working with this high risk fragile population in the NICU. Thickening may be contraindicated based on data obtained in radiology.

The author asks  “What if the baby can’t suck?” and then states that “all babies have a suck reflex”. Unfortunately, this is inaccurate. It is not uncommon that a sick newborn or some preterm infants with significant neurologic co-morbidities may not have a sucking reflex, or the suck lacks the integrity to feed orally. If  indeed this is the clinical presentation, thickeners would be contraindicated. Our  interventions for motor learning would go in a completely different direction, both in the NICU and after discharge.

In addition, the assumptions about the interventions described in the article for use with post NICU infants (e.g., bottle feeding thin liquid  to avoid maladaptive feeding patterns, use of glycerin swabs, ice chips, and anterior controlled placement of thin water) are worrisome and may mislead the reader as to the interventions most typically indicated for an infant just discharged from a neonatal intensive care unit. The infant post-NICU is often still quite immature overall, and interventions such as those suggested may both present undue risk to the airway and be poorly tolerated from a sensory and GI perspective. Indeed, safety of progressing the diet to thin liquids, if previously contraindicated, would best be considered for the NICU graduate in the setting of objective data regarding physiology in radiology. Many NICU graduates continue to have medical issues post discharge that can make airway invasion a compelling risk to both their pulmonary and overall health. 

Cichero, J A  et al (2013). Thickened milk for the management of feeding and swallowing issues in infants: a call for interdisciplinary professional guidelines. Journal of Human Lactation, 29(2), 132-135.

Duncan DR, Larson K, Davidson K, May K, Rahbar R, Rosen RL.(2019) Feeding interventions are associated with improved outcomes in
children with laryngeal penetration. J Pediatr Gastroenterol Nutr. 68(2):218–224.

Goldfield, EC  et al (2013) Preterm infant swallowing of thin and nectar-thick liquids: changes in lingual-palatal coordination and relation to bolus transit. Dysphagia 28, 234e244.

Gosa, MM & Corkins, M R(2015). Necrotizing enterocolitis and the use of thickened liquids for infants with dysphagia. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(2), 44-49.

Madhoun, LL et al (2015). Feed-thickening practices in NICUs in the current era: Variability in prescription and implementation patterns. Journal of Neonatal Nursing, 21(6), 255-262.

I appreciate the opportunity to share the perspective of an NICU SLP and hope this has been helpful.

Research Corner: Aspiration and Dysphagia in the Neonatal Patient

Raol, N., Schrepfer, T., & Hartnick, C. (2018). Aspiration and Dysphagia in the Neonatal Patient. Clinics in perinatology, 45(4), 645-660.


There are 3 major types of aspiration: anterograde (occurring before, during, and after the swallow), retrograde (as occurs with gastroesophageal reflux), and silent aspiration (no accompanying symptoms). Aspiration has the potential to cause permanent damage to the developing lungs of infants and children. Aspiration in children includes oral feeds and secretions (direct aspiration) and reflux contents (indirect aspiration). Pulmonary aspiration is present in one-half of pediatric patients with unexplained or refractory respiratory symptoms, such as cough. It can cause recurrent respiratory illness, pneumonia, and lung damage, requiring frequent hospitalizations.6 Etiologies of dysphagia and aspiration can be divided broadly into 5 categories:  Anatomic abnormalities (ie, craniofacial anomalies, laryngotracheoesophageal clefts, laryngomalacia);  Neurologic abnormalities (ie, intrauterine stroke, posterior fossa malformations, neuromuscular disorders);  Cardiopulmonary disease affecting the suck–swallow–breathe pattern (ie, bronchopulmonary dysplasia, cardiac disease, infection);  Gastrointestinal etiology (ie, reflux); and  Other/unknown.

The diagnosis and management of dysphagia and aspiration in neonates represent a significant challenge for physicians, with management requiring long-term medical supervision and attention. Without intervention, the patient may develop recurrent illness, inadequate nutrition, and the need for supplemental nutrition that, if continued for an extended period of time, may result in oral aversion and refusal behaviors. Successful management begins with a thorough evaluation with a complete history and physical examination and appropriate imaging studies to identify the etiology and potential targets for intervention.

Neonatal dysphagia and aspiration can be difficult to treat. Multiple etiologies can be responsible for feeding and swallowing issues, including prematurity, structural abnormalities, neurologic delay, infectious etiology, and reflux. Identifying the etiology will help to guide management. Multidisciplinary team management, including otolaryngology, neonatologists, speech-language pathologists is necessary to achieve optimal short and long-term outcomes in these patients.

Research Corner: Bronchopulmonary Dysplasia and Pulmonary Outcomes of Prematurity

Tracy, M. K., & Berkelhamer, S. K. (2019). Bronchopulmonary Dysplasia and Pulmonary Outcomes of Prematurity. Pediatric annals, 48(4), e148-e153.


Bronchopulmonary dysplasia (BPD) is a chronic lung disease most commonly seen in premature infants who require mechanical ventilation and oxygen therapy. Despite advances in neonatal care resulting in improved survival and decreased morbidity, limited progress has been made in reducing rates of BPD. Therapeutic options to protect the vulnerable developing lung are limited as are strategies to treat lung injury, resulting in ongoing concerns for long-term pulmonary morbidity after preterm birth. Lung protective strategies and optimal nutrition are recognized to improve pulmonary outcomes. However, characterization of late outcomes is challenged by rapid advances in neonatal care. As a result, current adult survivors reflect outdated medical practices. Although neonatal pulmonary disease tends to improve with growth, compromised respiratory health has been documented in young adult survivors of BPD. With improved survival of premature infants but limited progress in reducing rates of disease, BPD represents a growing burden on health care systems.

Comments from Catherine: This provides an excellent summary of pathophysiology, ventilation modes and outcomes for this fragile group of preterms who often have feeding and swallowing problems related to their Chronic Lung Disease and its sequealae.

Research Corner: Nonpharmacological and Pharmacological Measures in Neonates with Neonatal Abstinence Syndrome

Magyar, Hannah R.; Metzger, Laura D.; and Schrage, Ariel N., “Systematic Review: The Effects of Nonpharmacological and Pharmacological Measures in Neonates with Neonatal Abstinence Syndrome” (2019). Williams Honors College, Honors Research Projects. 889.


With the increasing incidence of drug addiction among pregnant women, neonatal abstinence syndrome (NAS) has become a significant problem in the United States and has led to increased hospital costs, longer lengths of stay, and more serious health problems in neonates. This systematic review will explore the evidence about outcome differences for neonates with NAS that receive breastfeeding, rooming-in, and acupuncture in addition to pharmacological agents when compared to infants only receiving pharmacological agents. Twenty-one articles, retrieved from the databases PubMed and CINAHL and published between the years 2000-2017, were described in an integrated review, analyzed with critical appraisal, and synthesized for this systematic review. In general, researchers have found that breastfeeding, rooming-in, and acupuncture have positive effects of decreasing the need for pharmacological treatment, NAS symptoms, hospital costs, and length of hospital stay for infants with NAS when used in conjunction with pharmacologic agents.

Research Corner: VFSS and Frame Rate

For those  of you not on the ASHA List Serve, I am sharing a post regarding a recent publication about frame rate for Pediatric Videofluroscopic Swallow Studies. The post was written by Heather Bonilha, PhD,  who is  a speech-language pathologist and medical researcher who specializes in voice and swallowing disorders. For over 15 years, she has been studying the impact of temporal resolution (ex. frame rate) on diagnostic accuracy and treatment recommendations with a specific focus on MBSSs. We are so grateful for contributions, and for her post, which infomrs our practice.

The recently published article is:  Layly, J., Marmouset, F., Chassagnon, G., Bertrand, P., Sirinelli, D., Cottier, J. P., & Morel, B. (2019). Can We Reduce Frame Rate to 15 Images per Second in Pediatric Videofluoroscopic Swallow Studies? Dysphagia. doi:10.1007/s00455-019-10027-8

To quote from her post:

 I am reaching out to the SIG13 forum to express my concerns related to a very recently published article: Layly, J., Marmouset, F., Chassagnon, G., Bertrand, P., Sirinelli, D., Cottier, J. P., & Morel, B. (2019). Can We Reduce Frame Rate to 15 Images per Second in Pediatric Videofluoroscopic Swallow Studies? Dysphagia. doi:10.1007/s00455-019-10027-8 I’ve never made a post like this but am compelled based on my concern for quality patient care to post this one. I want to informally point out some information that clinicians and researchers should consider when evaluating the merits of the article referenced above. 

Points to consider when evaluating the merit and clinical implications of the research article “Can We Reduce Frame Rate to 15 Images per Second in Pediatric Videofluoroscopic Swallow Studies?”:

The most significant point is that one can not notice a difference in something that isn’t there. When studying the impact of technical parameters of MBSS, one must use cases where the phenomenon (penetration / aspiration in this case) exists. If the patient doesn’t penetrate/ aspirate at 30 frames per second (fps) there is not a possibility to find it at 15fps, falsely leading to a result of agreement in diagnostic accuracy between 30 & 15 fps. Thus, any study of pulse rate / frame rate must be limited to that in which a phenomenon (penetration/aspiration, reduced laryngeal elevation, delayed initiation of pharyngeal swallow etc.) is detectable at 30fps. Therefore, of the 190 swallows studied in the above referenced article only 46 are pertinent to addressing the research question. By including all 190 swallows, the results of the study are significantly biased towards revealing no differences between 15 and 30fps.

Next, it is necessary to consider more than penetration/aspiration when determining whether technical factors influence diagnostic accuracy. Our treatments have a goal of reducing penetration/aspiration, but we do that by modifying swallowing physiology (not assessed by, for instance, by the penetration-aspiration scale (PAS)). Strong clinical implications regarding the suitability of using 15 vs 30fps must consider more than just PAS. The authors correctly state in the discussion that “15 fps may be adequate to record aspiration and penetration in children; however, more subtle biomechanical and kinematic phenomena may be missed at the slower sampling frequency due to the rapidity of the physiological swallowing components.”

The technique used to down sample the 30fps recording to 15fps does not allow the raters to be blinded to the higher versus lower frame rates as the higher frame rates (30 fps) will be twice as long as the 15fps swallows. There is a statement that using the 15fps recordings did not change the treatment plan for the patients. However, impact on treatment plan was not a variable in the research study and no data related to treatment plans / recommendations were presented.

There is a statement that using 15fps instead of 30fps is “an efficient way to reduce the ionizing radiation exposition in children”. However, radiation exposure, and more importantly, radiation risk, was not assessed in the study.

For these reasons, I strongly recommend a careful evaluation of the research methods and conclusions of the article “Can We Reduce Frame Rate to 15 Images per Second in Pediatric Videofluoroscopic Swallow Studies?” I will be formally writing a Letter to the Editor of Dysphagia; however, that is a lengthier process and I felt that the potential clinical ramifications dictated a more immediate response. Therefore, before the formal Letter to the Editor can be published, I hope that clinicians are encouraged to read the published article with critical appraisal prior to incorporating it in their evidence-based clinical practice.

Please feel free to contact me off-line at regarding this. Sincerely,

Heather Bonilha  

Bonilha, H.S., Blair, J., Carnes, B., Huda, W., McGrattan, K., Humphries, K., Michaels, Y., Martin-Harris, B. (2013). Preliminary investigation of the effect of pulse rate on judgments of swallowing impairment and treatment recommendations. Dysphagia, 28(4): 528-538. [PMID: 23559454] [PMCID: PMC3762944]

Bonilha, H.S., Huda, W., Wilmskoetter, J., Martin-Harris, B., Tipnis, S.V. (2019). Radiation risks to adult patients undergoing Modified Barium Swallow Studies. Dysphagia. [PMID: 30830303] [PMC Journal – In Process]

Bonilha, H.S., Wilmskoetter, J., Tipnis, S.V., Martin-Harris, B., Huda, W. (2019). Relationships between Dose Area Product, radiation exposure time and projection in adult Modified Barium Swallow Studies. American Journal of Speech-Language Pathology. [PMC Journal – In Process]

Bonilha, H.S., Wilmskoetter, J., Tipnis, S.V., Martin-Harris, B., Huda, W. (2018). Estimating thyroid doses in Modified Barium Swallow Studies. Health Physics, 115(3): 360-368. [PMID: 30045116] [PMC Journal – In Process]

Bonilha, H.S., Wilmskoetter, J., Martin-Harris, B., Tipnis, S.V., Huda, W. (2017). Effective dose per unit kerma area product conversion factors in adults undergoing Modified Barium Swallow Studies. Radiation Protection Dosimetry, 16:1-9. [PMID: 28204745] [PMCID: PMC5927331]

Bonilha, H.S., Humphries, K., Blair, J., Hill, E., McGrattan, K., Carnes, B., Huda, W., Martin-Harris, B. (2013). Radiation exposure time during MBSS: Influence of swallowing impairment severity, medical diagnosis, clinician experience, and standardized protocol use. Dysphagia, 28(1): 77-85. PMID: 22692431

Martin-Harris, B., Carson, K.A., Pinto, J.M., Lefton-Greif, M.A. (2019). BaByVFSSImP© A novel measurement tool for videofluoroscopic assessment of swallowing impairment in bottle-fed babies: establishing a standard. Dysphagia. [PMID 30955137]

Lefton-Greif, M.A., Arvedson, J.C. (2016). Pediatric feeding/swallowing: yesterday, today and tomorrow. Semin Speech Lang 37:298-309. [PMID 27701706]

Arvedson, J.C., Lefton-Greif, M.A. (2017). Instrumental assessment of pediatric dysphagia. Semin Speech Lang 38:135-146. [PMID 28324903]

Problem-Solving: NICU Safety Concern

Question: I work in a NICU and am having difficulty with one of the Neonatologists. He changes nipple flow rates to see if volume will improve despite detailed documentation from therapists and nurses related to poor feeding quality, liquid loss, disengagement, occasional coughing and wet breathing with the faster flow nipple. Orders are changed requiring caregivers to use the faster nipple basically tying their hands behind their back regarding following the infants lead. I still use the slower nipple regardless and try to educate. Last time this happened, we spoke to the ‘head physician’ and were told that although my services were consulted, it’s is the physician’s decision to make. The question I want to throw out is…. In this case, is it expected that I sign off as the recommendations are not followed after education and discussions? Do I stay on to provide quality oral experiences 3-5 feedings per week, only? Not sure what the expectation is at this point.

Answer: This is unfortunately a more common situation than one might think. As I travel to teach about the NICU across the US and beyond, all too often this is a topic of discussion, as many SLPs who are part of NICU teams experience such a dilemma. Volume driven feeding in the NICU continues to be a challenge to neuroprotection and swallowing safety, and creates not only concerns for airway invasion but also learned aversions and maladaptive behaviors. The push to “get babies out”, lack of awareness and/or understanding of current research, combined with old habits of “getting it in”, combine to make our work in the NICU both challenging, at times disheartening and at times exhausting. Continuing to bring the research, using each consult as an opportunity to dialogue and letting the medical team “think along with you” about physiology, medical co-morbidities in the NICU and their relationship to feeding/swallowing, using guided participation with nurses and partnering with RNs who “get it” continue to be ways we can articulate our value. But in these situations as you describe, there is no clear answer. One option is to sign off, but then we cannot even advocate to protect the infant, support parent learning and reconsideration of their infant’s communication, identify onset of resulting aversions, or try to optimize safety with interventions. And we often cannot continue the dialogue about that infant and his response to the faster flow that may continue to go unrecognized by well-intentioned caregivers. And we lose an opportunity to turn the tide. I recognize it is a high and strong tide, one I have been dealing with since 1985 when I first set foot in a neonatal intensive care unit. Our resilience matters for the preterm and sick term infants in our care in the NICU, and their futures. Working in the NICU is indeed a step at a time each day, and requires much of those who choose to be there. The changes one can see over time keep us going and we support each other to have the courage and confidence to do so. I hope this helps