Research Corner: Predicting Aspiration Risk in Children

Duncan, D. R., Mitchell, P. D., Larson, K., & Rosen, R. L. (2018). Presenting Signs and Symptoms do not Predict Aspiration Risk in Children. The Journal of Pediatrics.


To determine if any presenting symptoms are associated with aspiration risk, and to evaluate the reliability of clinical feeding evaluation (CFE) in diagnosing aspiration compared with videofluoroscopic swallow study (VFSS).

Study design

We retrospectively reviewed records of children under 2 years of age who had evaluation for oropharyngeal dysphagia by CFE and VFSS at Boston Children’s Hospital and compared presenting symptoms, symptom timing, and CFE and VFSS results. We investigated the relationship between symptom presence and aspiration using the Fisher exact test and stepwise logistic regression with adjustment for comorbidities. CFE and VFSS results were compared using the McNemar test. Intervals from CFE to VFSS were compared using the Student t test.


A total of 412 subjects with mean (±SD) age 8.9 ± 6.9 months were evaluated. No symptom, including timing relative to meals, predicted aspiration on VFSS. This lack of association between symptoms and VFSS results persisted even in the adjusted multivariate model. The sensitivity of CFE for predicting aspiration by VFSS was 44%. Patients with a reassuring CFE waited 28.2 ± 8.5 days longer for confirmatory VFSS compared with those with a concerning CFE (P < .05).


Presenting symptoms are varied in patients with aspiration and cannot be relied upon to determine which patients have aspiration on VFSS. The CFE does not have the sensitivity to consistently diagnose aspiration so a VFSS should be performed in persistently symptomatic patients.


Problem-Solving: Aerophagia in infant with cleft lip


One of my friends just had a baby with a partial cleft lip. She is 6 weeks old and started having trouble with feeding last week. Her pediatrician feels like she is sucking too much air in when feeding. The mother has tried different bottles and nipples. She is on thin formula. She is also having diarrhea and her bottom is raw. Her pediatrician feels like it is caused from the air coming in from her cleft during bottle feeds. She has a cleft lip repair surgery date set in September. What recommendations should if give her? Applying chin support and pressure to cheeks to get a good lip seal? Thickening the formula to slow the flow rate?

Thank you for any advice!


It is uncommon for a partial/incomplete cleft in isolation to lead to the feeding problems you describe. In my experience, an isolated cleft of the lip does not contribute to feeding problems in infants. It can, however, co-occur with other alterations in oral-motor/structural integrity. These would include: a cleft of the soft palate (even just the uvula) that is not readily apparent to the physician – it would alter the effectiveness of intra-oral suction and lead to ineffective compensatory sucking behaviors that may lead to air swallowing. Other possibilities are a tongue tie (posterior and/or anterior, as these often co-occur with clefts d/t timing of intrauterine aerodigestive structure formation; the tongue tie(s), if present, can lead to ineffective tongue-palate seal and again, air swallowing with each bolus, as well as fatigue and decreased transfer of milk. Another option is that there is co-occurring mandibular hypoplasia (a retruded and/or small jaw, as we used to call it – ENTs typically call it mandibular hypoplasia); this can lead again to poor tongue-palate seal, ineffective tongue patterns for sucking d/t altered intrauterine motor-learning by the tongue, and again compensatory sucking patterns that become maladaptive and not functional. Another possibility is a submucous cleft, which again may not be clear, and lead to ineffective suction, leading to the same maladaptations and adverse functional sequelae.

She may also have altered sucking or coordination patterns unrelated to any structural differences, just “co-occurring”, that has the same undesired results. For example, she may also have a prolonged sucking pattern that can lead to air swallowing. In that case, co-regulated pacing would support a more stable burst-pause pattern and avoid air swallowing,  or the flow are may be too fast, which can lead to swallowing air with each bolus, so a more controllable flow rate would help (i.e., slow flow). I would not thicken liquids or continue changing nipples, as her learning starts over each time, and some of that may be maladaptive. We really need is to understand the “whys” before we can determine what interventions would be indicated.

The loose stools also are concerning for poor formula tolerance or other GI issues that may further adversely affect feeding pleasure and growth. A consult with a pediatric SLP, ENT and GI would be beneficial to complete a thorough differential to find out what is contributing to her poor feeding.

Research Corner: Psychometric Properties of the Early Feeding Skills (EFS) Assessment Tool

Wanted to update you on a new manuscript about the EFS which I co-authored that is now in press with Advances in Neonatal Care.  Abstract below – Dr. Thoyre and I hope to see it published ahead of print in the next few weeks. We are very excited that the psychometrics of the EFS, demonstrating its reliability and validity, will soon be published. 

Psychometric Properties of the Early Feeding Skills (EFS) Assessment Tool Abstract

 Background: Supporting infants as they develop feeding skills is an essential component of neonatal and pediatric care. Selecting appropriate and supportive interventions begins with thorough assessment of the infant’s skills. The Early Feeding Skills (EFS) tool is a clinician-reported instrument developed to assess the emergence of early feeding skills and identify domains in need of intervention.

Purpose: The purpose of this study was to identify the factor structure of the EFS and test its psychometric properties, including internal consistency reliability and construct validity.

Methods: EFS-trained inter-professional clinicians in three settings scored 142 feeding observations of infants aged 33 to 50 weeks postmenstrual age. Redundant and rarely-endorsed items were removed. Factor-analysis methods clustered items into subscales. Construct validity was examined through the association of the EFS with (1) concurrently scored Infant-Driven Feeding Scale-Quality (IDFS-Q), (2) infant birth risk (gestational age), and (3) maturity (postmenstrual age).

Results: Principal components analysis with varimax rotation supported a 5-factor structure. The total EFS demonstrated good internal consistency reliability (Cronbach’s α = .81). The total EFS score had construct validity with the IDFS-Q (r = -.73; p < .01), and with gestational age of a subsample of premature infants (= .22; p < .05).

Implications for Practice: As a valid and reliable tool, the EFS can assist the inter-professional feeding team to organize feeding assessment and plan care.

Implications for Research: The strong psychometric properties of the EFS support its use in future research.

Please plan to join Dr. Suzanne Thoyre and I on August 15thand 16th for a Train-the-Trainer session on the EFS Tool in Atlanta, GA. 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. 

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





Problem Solving: Infant with Laryngomalacia

QUESTION: I am providing swallowing therapy in a rural EI home.  The PT is a 7 month old male with a history of plagiocephaly, laryngomalacia and glottal surgery.    He demonstrated coughing with feedings and apneic episodes (awake and asleep), prior to surgery with no cyanotic episodes.  When I started treatment, he was 4 months old, post surgery and MBS.

The MBS reported:  Thin liquid-not enough swallows to be diagnostic due to limited latch.   Thickened 1Tbs to 2oz.-consistent, shallow swallows with small volume penetration, which eventually led to silent aspiration.  Suspected aspiration was due to large bolus size as a Level 3 MAM nipple was used.  Thickened 1 to 1 with level 3 nipple-WFL extraction and bolus size, timely swallow initiation, vallecular and pyriform residue observed but PT cleared.

He would not accept the 1-1 thickened feeds at home, so it was decreased 3 to 1 using oatmeal cereal.

The feeding clinic at nearest pediatric hospital recommended introducing plastic juice box and NUK brush to address his oral aversion to the bottle.  In therapy, I instead coached parents to focus on gentle bottle feedings, anticipating readiness to accept bottle and reading the baby’s cues during the feedings and taking breaks when needed, keeping feedings at 15-20 minutes.  This has proved successful.  He takes 3-4 oz at a feeding with 24 plus oz per day.   Mom has been able to return to work and the sitter can also confidently feed him the bottle. He is accepting small amounts of baby food and meltables.  The ENT recently tried to eliminate Zantac but he presented with increase emesis. He is back on the Zantac.  He continues to do best during feedings if he falls asleep with pacifier and then mom presents bottle.  He often reaches for the bottle, smiling and puts in his mouth, but intake is higher and pacing smoother with “sleepy feedings.”  Any thoughts on this????

My other question:  We have decreased thickening to 2.5 Tbs to 4 oz using a new Level 3 nipple.  With the info from the MBS would you decrease thickening further with use of slower flow nipples and how would you structure the decrease?

Thank you for advice in advance!!


ANSWER:    I suspect he had a supraglottoplasty which has been correlated in multiple papers in the literature with post-procedure continued impairment in swallowing physiology leading to silent aspiration. Typically, even post-op there continues to be a significant increase in WOB; because we do not know his birth history and early history, it is unclear if there were other co-morbidities whose sequelae may be part of his clinical presentation and therefore need to be a part of the differential.

His respiratory behaviors (both WOB and RR) are missing pieces of the puzzle for me, as these are common areas of challenge with his history. Because infants with LM often have increased WOB and intermittent tachypnea even post-op, I wonder what impact that had on his reluctance during the VFSS to suck (i.e. the need to breathe overrides sucking drive). This can lead to adaptive/compensatory behaviors of not wanting to latch, latching loosely and not transferring milk purposefully. In addition, the flow rate from the MAM, if it was competing with breathing, may have adversely affected the data set.

The information from the instrumental assessment is difficult to understand, because the terminology used in the report is not clear. The usefulness of the data gathered at that VFSS is limited, in that only a MAM nipple was used as they tend to flow faster, and infants S/P supraglottoplasty, if they do PO feed, benefit from optimal flow rate control without the need for thickening (such as a Dr. Browns’ Ultra Preemie or a preemie nipple). In my clinical experience with infants with LM post supraglottoplasty, thickened feedings can themselves create safety issues during a true feeding, related to residue and changes in structural integrity of the airway after surgery. Another consideration is that if we are altering the thickener or level of thickening based only on clinical observations is problematic, especially in the setting of his known silent aspiration. Also, we unfortunately know nothing about the etiology of the airway invasion reported nor if interventions were utilized during the procedure (such as resting and co-regulated pacing) which are crucial interventions for infants with his diagnosis post-op.

I would strongly suggest a repeat instrumental assessment of his physiology by a pediatric trained SLP. The last VFSS appears to have been 3+months ago, and the time from 4 months to 7 months of age, even for the normally- developing infant, is one of great change (structurally and with regards to physiology). It would allow a look at such as a Dr. Browns’ Ultra Preemie or a preemie nipple and use of resting and co-regulated pacing during the procedure. You could then also objectify physiology with the purees and meltables you have started since the last study.

Odd the ENT was planning to d/c the Zantac, as our ENTs typically max-out reflux meds post procedure. This is because it is common for LM and EERD to co-occur, and indeed EERD can cause/exacerbate airway edema and adversely affect laryngeal sensation, which in turn increases the likelihood that events of airway invasion will be silent.

The sleep feeding may indeed be r/t EERD and may also be an attempt to avoid the discomfort or pain associated with eating. Is a pediatric GI doc involved? If his apparent EERD is better managed perhaps the need to sleep fed may be less prominent and he can be guided to be more of an active participant via sensory-motor warm ups prior to feeding. It is likely the plagiocephaly and the torticollis are altering quality of postural/sensory-motor skills (head/neck/shoulder girdle/trunk) , despite perhaps milestones themselves reportedly “approximating” his age level; they may also be altering some of the qualitative aspects of swallowing and feeding, since the head/neck/shoulder girdle/trunk, and even the hips/pelvis, all contribute to form the foundation for feeding and swallowing At his age and with his postural/airway/likely breathing co-morbidities, we need him awake actively learning during feeding , both for better airway protection and for oral-motor learning prerequisite to future skills.

I hope this is helpful. He is quite a complex patient.



Problem-Solving: 4 y/o with trach CP

Question: We are currently seeing a 4 year 11-month-old female born at 31 weeks gestational age with an undiagnosed neuromuscular disorder. She presents with global developmental delay, chronic oxygen requirement (<0.5L at 21%), trach dependent with suctioning requirement 1-2x per hour orally and within the trach. This patient can tolerate wearing a PMV for greater than 60 minutes but no distinguishable difference in swallow safety or timing during MBS. She has global gross motor delays, can sit independently but unable to crawl or transition from lying to sitting. She has severe cognitive delays but does communicate with use of head nodding/shaking and signs within routine based activities.

Patient’s parent’s primary goal is for the patient to eat orally. She has been receiving speech therapy services targeting dysphagia including use of NMES, thermal tactile stimulation, jaw stability (kinesiotape), and oral trials of tastes (flavor spray and hard munchables with strong flavor with clearing and oral care by SLP) only. We have previously trialed: Large bolus size to increase sensation, strong flavors, use of assisted jaw closure and focus on labial closure. Patient’s spontaneous swallows range from 1-8 swallows within a 60-minute session. She silently aspirates consistently on MBS on all consistencies. Per result of MBS patient lacks velar engagement or elevation and has bolus movement into the nasal cavity during attempted initiation of swallows. She is also unable to maintain a labial seal.

Please provide any treatment ideas we have not considered. We appreciate your time.


Answer: What a difficult patient. I am happy to provide informal guidance that may assist you in your ultimate management plan.

At almost 5, her multiple co-morbidities reflect the severity of her dysphagia. So many pieces. You are trying, I can tell, to pull together any possible way to help meet the goal set by her family, that she be an oral feeder. The problem is that the goal is most likely not attainable for right now, and perhaps may never be, due to the severe level of impairment both overall and specific to her dysphagia. Let me try to explain why this is my impression.

Her postural control, based on what we know, is a fundamental component for her poor swallowing integrity. The poor stability and strength we see in her body is likely mirrored in her oral-pharyngeal mechanism.

I don’t think her palate problem (“lack of velar engagement or elevation”) is a “palate problem” per se but, given her clinical presentation, and the bigger picture, what was inadvertently perceived as “lack of velar engagement or elevation” reflects the nature of her swallowing impairment. I suspect that the “bolus movement into the nasal cavity during attempted initiation of swallows” most likely reflects passive retrograde flow into the nasopharynx, due to a severe delay in swallow initiation. The bolus is moving passively into the nasopharynx, just like it moves passively into the airway and is aspirated. This may be due to a combination of poor sensation, poor driving force of the tongue and poor driving force on the bolus anteriorly (poor lip seal described). Likely that her pharyngeal constrictors are also lax and contribute to bolus mis-direction to both the nasal and laryngeal airways – all associated with hypotonia. Given her described MA (severe cognitive delays), she likely lacks not only the postural but also the cortical neural underpinnings to be able to chew the hard munchables described. Her need for suctioning suggests she does not swallow her saliva, which is often associated with such a severe delay in swallow initiation and sensory-motor deficits as described. She requires a trach but it’s not clear how long it has been in place. It is clearly providing a current means of pulmonary toileting (suctioning) but may have been placed secondary to past need for ventilator support given her undiagnosed neuromuscular disease; she wears a PMV but has significant suctioning needs; this suggests she is not perceiving her secretions despite restoration of oral airflow by the PMV and is not swallowing her saliva.

Given this, I would suggest not offering her hard munchables, based on the impairments in her swallowing physiology, as she appears to lack the many prerequisites for chewing, so the hard munchables may be silently aspirated and/or obstruct her airway. While use of a larger bolus for increased sensation may be somewhat helpful under a different clinical situation, it may be problematic for her, given her hypotonia; she is likely to not sense that large bolus, too, and there is risk for it to move with gravity silently. Her poor jaw stability and lack of lip closure are both likely secondary to poor oral stability and oral hypotonia, so passive attempts at closure/approximation to swallow would be just that and won’t impact the underlying neuromotor components needed to swallow.

PT/OT are most critical interventions currently to build the postural base/framework to support swallowing of saliva as a starting point. You might work in co-therapy with them, while they are working on postural stability and support; you could provide deep pressure tactile input to the base of the tongue, onto into the biting surfaces of the teeth, offer a biter/teether to provide deep pressure input into the mandible (via the biting surfaces), deep pressure into the blade of the tongue to promote active tongue movement and driving force. An NDT trained SLP could guide you through this approach. I would also focus on tolerance of tooth brushing to promote optimal oral hygiene. Use of good oral care before any oral intervention is essential to reduce potential for bacteria laden oral secretions move into her lungs during therapy activities. Flavor spray on the biter/teether might be permitted but given her ongoing needs for flow (21% Fi02), the spray can mix with saliva and then be aspirated as well; check with her pulmonologist for guidance with this, as well as any tastes being offered. Because she is a known silent aspirator with multiple co-morbidities, with likely immunocompromise, even therapeutic tastes may not be appropriate. I would be having a conversation with her primary physician (and/or a key specialist like pulmonology) to ask for support in discussing with the family that PO feeding in the short term is very likely to place her at risk for re-hospitalization. Helping them understand the neural (cortical), postural, and sensory prerequisites will be helpful. A goal for them would be for her to swallow her saliva, as that suggests that the prerequisites for PO feeding trials are in closer reach.

These are such hard conversations to have, as families of children with such all-encompassing co-morbidities want their children to eat and we understand that deep longing. We never want to take their hope away and must give them guarded optimism, but at the same time be realistic and specific about what is within our clinical expertise to change at given points in the child’s developmental trajectory. Never hesitate to tell the family that it is hard for you to tell them what you must, and that you are not giving up on their child but also must assure that everyone is on the same page about what will help now and focus on the “now”.

You are thoughtful and kind, and the family is fortunate to have you in their corner.

I hope this is helpful.


Research Corner: Supporting Neurodevelopmental Outcomes in Infants and Children with Congenital Heart Disease

Supporting Optimal Neurodevelopmental Outcomes in Infants and Children with Congenital Heart Disease

Peterson, Jennifer K. “Supporting Optimal Neurodevelopmental Outcomes in Infants and Children with Congenital Heart Disease.” Critical Care Nurse 38, no. 3 (2018): 75-79.

Our fragile infants and children with congenital heart disease are at risk for adverse developmental outcomes across multiple domains, including feeding/swallowing. This just-published article speaks to critical interventions, among them, cue-based feeding.


Improved survival has led to increased recognition of developmental delays in infants and children with congenital heart disease. Risk factors for developmental delays in congenital heart disease survivors may not be modifiable; therefore, it is important that lifesaving, high-technology critical care interventions be combined with nursing interventions that are also developmentally supportive. Implementing developmental care in a pediatric cardiac intensive care unit requires change implementation strategies and widespread support from all levels of health care professionals. This manuscript reviews developmentally supportive interventions such as massage, developmentally supportive positioning, kangaroo care, cue-based feeding, effective pain/anxiety management, and procedural preparation and identifies strategies to implement developmentally supportive interventions in the care of infants and children with congenital heart disease. Improving developmental support for these infants and children at high risk for developmental delay may improve their outcomes and help promote family-centered care.

Read more:

Research Corner: Therapy Usage in the NICU

Therapy Usage in the NICU

Ross, K., Heiny, E., Conner, S., Spener, P., & Pineda, R. (2017). Occupational therapy, physical therapy and speech-language pathology in the neonatal intensive care unit: Patterns of therapy usage in a level IV NICU. Research in developmental disabilities, 64, 108-117.

This article by Bobbi Pineda OTR and her colleagues provides valuable information about utilization of therapy services in a large NICU. It provides insight into referral patterns and supports the concept of early and continued therapy services throughout the NICU stay to optimize outcomes. While their findings are not necessarily generalizable to other NICUs, this is the first attempt to gather such data.

It is worrisome to me that for those NICUs in which SLPs support feeding, referrals are often not received until > 36 weeks PMA. By that time, many of our fragile preterms (with complex co-morbidities) have already struggled learning to feed and may be referred at that time for extra support to “fix them”. In NICUs where PT/OT support feeding, they are typically already following the infants when feeding readiness is a focus, so for those infants whose team is likely to require extra support for feeding, it is already in place. My hope is that there will be greater recognition of the importance of early additional feeding support to the team for those preterm infants at the highest risk for enduring feeding problems, as profiled in the literature. The complex nature of their poor feeding often requires a team approach to avoid maladaptive behaviors and airway invasion. More research is needed to explore this concept and articulate infant needs for support related to co-morbidities.

Research Corner: Tube Fed Children….Management, Weaning and Emotional Considerations

Tube Fed Children: Management, Weaning and Emotional Considerations

Edwards, S., Davis, A. M., Bruce, A., Mousa, H., Lyman, B., Cocjin, J., … & Hyman, P. (2016). Caring for tube-fed children: a review of management, tube weaning, and emotional considerations. Journal of Parenteral and Enteral Nutrition, 40(5), 616-622.

Working with our infants and children who are tube fed can be challenging. This more recent article by a well-respected interdisciplinary team highlights some key perspectives and current data that can inform your therapy practice. Hope you enjoy it as much as I did.


Research Corner: Feeding Problems from the Parents’ Perspective

Feeding Problems from the Parents’ Perspective

Estrem, H. H., Pados, B. F., Thoyre, S., Knafl, K., McComish, C., & Park, J. (2016). Concept of pediatric feeding problems from the parent perspective. MCN: The American Journal of Maternal/Child Nursing, 41(4), 212-220.

Wanted to share this recent article that so well captures the importance of the family as the most important part of our therapy with their child. As the authors state: “A child and their family have a feeding problem; they experience this journey together. It is more inclusive to consider this issue in the context of the child’s natural environment with the people who are most familiar and invested. A shared conceptualization that families can relate to (without perceived stigma), and that providers could use to classify pediatric feeding problems, would improve potential for early feeding assessment, referral, and for feeding intervention efficacy to last long term.”

Research Corner: Brain Oriented Care in the NICU

Brain Oriented Care in the NICU 

I wanted to share with those of you who are part of an NICU team or provide services for NICU graduates an article that, while 4 years old, is still so applicable as we support change from a volume-driven to an infant-guided feeding culture in the NICU. Those of you have an interest in neuroprotection for fragile adults will also find it interesting.

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

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

I hope you find this informative.


Problem Solving: Feeding Readiness in the NICU

Question: Non-nutritive oral motor therapy in NICU – when do you use it and why and what result do you see? As a warm up to oral feeding to help organize? In 30-32 weekers to prepare for oral feeding? In patients who would be nil by mouth for an extended time? Patients who are not able to feed orally due to severe aversion (usually due to gastro issues)? What is the latest research on this? I’ve read articles for and against.

Answer: A few thoughts for you. I don’t conceptualize what I think you are describing as oral motor but rather “feeding readiness”, which encompasses a different concept, a much broader, yet more defined, infant-guided approach in the context of the preterm’s unique co-morbidities.

Conceptualizing the feeding-related services we provide in the NICU as “feeding readiness” and “supporting safe/functional PO feeding” can help neonatal nurses and neonatologists better understand the value we add to the NICU team. Unfortunately, well-intentioned but stressful cares and/or feedings may wire the infant’s brain away from eating, and indeed lead to later feeding aversions. The literature on feeding outcomes in former preterms includes reflections on the high percentage of former preemies with enduring feeding problems, far beyond the NICU. It impacts the infant-parent relationship and multiple domains.

I would avoid “oral-motor work” designed to focus on oral-motor skills per se at this juncture as it would be too invasive and not appropriate. You are describing preterms who are both fragile and still many weeks prior to term. Were they not born too soon, they would be fetuses experiencing motor learning and oral-motor learning in utero; their oral-motor movement patterns would be evolving in the context of the containment provided by the uterus, with hands on their face and in their mouth (and alternating touching the placenta per research). Careful attention must be paid to physiologic stability, especially its impact on WOB and RR., during all infant-guided readiness experiences Progression to pacifier offered via rooting response for sucking with co-regulated pacing, f/b tiny droplets of EBM on a pacifier offered via rooting response for purposeful swallows They would be integrating their structurally-intact aero-digestive system by 17 weeks of life, swallowing several ounces of amniotic fluid each day.

Focus on structuring experiences outside of the uterus that most closely align with the ideal sensory-motor environment (intrauterine)and help caregivers embrace the critical impact this intervention can have if offered in a neuroprotective infant-guided way.

Also, know that in addition the benefits of mother’s milk (EBM) to the mucosa via tiny trace droplets that may promote purposeful swallows and oral-sensory-motor mapping is being considered by many NICUs as an early approach to supporting readiness for infant-guided feeding in the future prime the sensory-motor system along with nuzzling at the breast (kangaroo mother care). There is a very tiny “paintbrush” one of the reps has (sorry I cannot recall which) that can support a very gentle limited offering of MBM to the lips or this could be offered via very gentle well-graded touch. But one can do this with gentle infant-guided touch via a caregiver’s gloved finger as well.

The key is that any feeding readiness experiences should be offered when infant is at his best respiratory wise (both in terms of respiratory support being required and his WOB and RR), he is actively engaged and maintains physiologic stability, and should be offered using infant-guided principles of interaction. Resting the infant and use of co-regulated pacing to assure that respiratory stability is fostered from moment to moment, are essential to support a neuro-protective experience that promotes both safety and positive learning. Some NICU caregivers offering EBM may need guidance to view this experience in such a light, as opposed to a “task” that one “must complete as a part of cares” .
We recognize that, in the NICU, “practice” is not the key, but what is, is the experience, and how it is both offered and received by the immature emerging neuronal pathways and oral-sensory-motor system.

In the NICU, every experience matters, as I like to say. Practice in and of itself, only makes permanent the neuronal pathways that are recruited and mapped; it does not in and of itself create the pathways that underlie function or skill; it can unfortunately lead to maladaptive behavior and stress if done as a task and/or offered in a programmed way. Infant-guided experiences are essential to neuroprotection.

I teach these concepts and their underpinnings in my NICU seminar and cite relevant research, but I have yet to find anything published or researched specific to what I am describing, which provides the supported oral-sensory-motor learning I find so beneficial to our preterms. Its evolution is a part of my practice since 1985 in Level IV NICUs.
I hope this is helpful.



Research Corner: GER/EER in the NICU

Schurr, P., & Findlater, C. (2012). Neonatal Mythbusters: Evaluating the Evidence For and Against Pharmacologic and Nonpharmacologic Management of Gastroesophageal Reflux. Neonatal Network, 31(4), 229-241.

Reflux is a common issue in the NICU and with many of our pediatric patients. The evidence-base for effective interventions continues to  emerge related to preterm infants in the NICU. This paper by an NICU nurse published in 2012 is a fabulous resource. It does not just provide strategies but looks at the current evidence base as of its publication and explains so well the “whys” behind the interventions. It is so easy to join a bandwagon and support the latest idea but having the rationale and the data to titrate the interventions based on the unique issues and co-morbidities of a specific population, such as the NICU, is essential. It will inform your practice!

Problem Solving: Preterms with possible tongue tie


I am feeding a bit frustrated and just curious what others are thinking. I recently worked with twins in the NICU:  born at 24 + 6, BPD, one with history of bowel perforation and IVH grade II and the other with PVL. Both had G tubes placed while in NICU.  I did VFSS on both while in NICU. One did well with small volumes; she was able to DC home with small amounts of thin liquids via preemie nipple and small amounts of breast feeding. She was making slow but steady gains and showed good comfort.   The other one had some difficulty with swallow safety with abnormal VFSS.  He DC to home on small volumes thickened liquids via bottle and mom was also working on small trials of breast feeding with him as well.  Wonderful parents.  The babies had fantastic and very consistent RNs during their NICU stay; it was one of those times where you felt like everything was working well for these babies with histories of extremely preterm births and multiple co-morbidities.  The parents set up OP therapy services right away; they were told fairly quickly that both babies had tongue / lip / cheek ties and would benefit from a consult with a dentist to do the releases. The RN and neonatology staff came to me immediately and questioned this as the parents had reached out to them with concern.  I advised then to suggest the parents get a second opinion from one our ENTs who routinely work with our NICU babies during their stays and on follow up.  Thoughts?


We do see preterm infants with lip and tongue ties that can adversely affect lingual thinning and cupping and effectiveness of tongue-palate seal. This in turn can lead to diminished volume transfer and lead to early fatigue, as the ineffective effort yields less than ideal intake and tires the infant. The infants you describe however also clearly have additional/other potential etiologies for their limited PO intake (24 weeks, CLD, GI and neuro co-morbidities).

The possible restrictions as identified by the OP SLP, if they are indeed present, could further contribute to their feeding challenges. However, the ties in and of themselves, if they are present, are likely not the reason these infants required G-Tubes, rather, their co-morbidities were. The ties would create further struggle.

Unfortunately, depending on how the OP SLP explained her concerns to the parents and how much she considered the co-morbidities these twins present (which are known to highly influence feeding success), there may have been the impression created that the G-Tubes were “not necessary”. The OP SLP may have been clear that the ties would create further challenges and weren’t the primary problem, yet the family, wanting to hear the G-Tubes were “never necessary”, took away a much different message. The NICU team (who hopefully recognizes the co-morbidities these twins presented are associated with increased G-Tube requirements), had an obligation to explain (or re-explain) the bigger picture to the family –i.e., co-morbidities matter when it comes to feeding (research shows that), and,  if there are indeed ties, which can unfortunately be missed at times, then correcting the ties, if ENT chooses to do so, would not change the need for the G-Tubes.

It is all too easy to instead assume that missing the ties, if they indeed exist, is why the infants received G-Tubes. Well-intentioned NICU staff may have reacted without understanding that “co-morbidities matter” (this is my most-used mantra during my NICU work and teaching) — but they do! Too often it seems co-morbidities don’t matter, as decisions/prognoses/plans about feeding are made by the medical team without regard to the infant’s co-morbidities. I find if we follow the co-morbidities, then our differential, prognosis and plans for these infants are likely to be appropriate.

I would reach out to the OP SLP, find out what she noted as indications of ties exist that might have been missed, share insights regarding the stamina and co-morbidities that created the need for GTube while you followed them in the NICU, and build a relationship through which there can be sharing and learning.  

I would also follow-up with my NICU colleagues to continue the conversation and reinforce the bigger picture that I referenced above. Too often SLPs can become the “reason” a preemie gets a GTube, or so it seems. This notion, which can discredit us as a profession or as individuals unfortunately in the eyes (and voices!) of some team members, and then by connection, some families, will change only with continued conversations. This is one of those times, Linda. Your likely recommendation for a GTube during their NICU stay wasn’t made lightly and I am confident was appropriate. The dialogue you have now is important for you, your team and for families fortunate to have your care in the future.

I hope this is helpful.



Problem Solving: Reflux in the NICU


Regarding NICU preemies/infants, what are recommendations/guidelines utilized for concern with reflux (e.g., thickener, rice)? Are more behavioral and positioning strategies utilized first (e.g., HOB elevation, hold upright 30 min after feed) or is initiation of formula change/diagnostic imaging (MBSS) preferred? Also, if thickening, is there another approved way besides rice?


I am responding specifically to preterms in the NICU. Those discharged to home may have GI follow and/or pediatricians manage their care, which allows for more options and perhaps even more variation in practice. There are no agreed upon guidelines from NICU to NICU, often there is variability even among your group of neonatologists. Let me share what they and my GI friends have kindly taught me over the years along with what I have learned along the way.

They tell me that the lack of agreement is d/t the absence of compelling literature that clearly guides them, especially when it comes to use of medications for EERD/GERD. That said, a recent study brought to our team by our pharmacist concluded that PPIs can cause significant problems for preterms (increased risk of NEC, sepsis/bacteremia, PNA and GI infections; decreased absorption of nutrients such a calcium, iron, zinc, magnesium, B12 –and zinc is essential to function of their immune system). While use of medications has typically been infrequent and a last resort approach in the Level IV NICUs I have been a part of, evidence such as this has further decrease their use, understandably so. When risk benefit ratio is not clear, physicians will be cautious. There is risk with thickened feedings as well (such as adverse effect on GI emptying which can worsen reflux, constipation, increased risk for NEC, alterations in C02); if thickening for reflux, what is used and how much is quiet variable again r/t MD differences. Most often rice is utilized but it too can have attendant sequelae as mentioned previously, as well as potential allergenic responses and concerns for arsenic.

Instead reflux precautions are typically the first line of defense (elevating head of bed, L side down post feeding for the first hour, R side down for the second hour and beyond – when monitored; upright carry position on caregiver’s shoulder post feeding when held); avoid medium or fast flow nipples that might lead to air swallowing and exacerbate EERD/GERD, utilize co-regulated pacing to avoid air swallowing, frequent gentle burps, use of elevated elongated sidelying position for feeding (to minimize pressure gradients throughout the abdominal area that might inadvertently increase propensity for reflux).

Pump feedings that allow a slower delivery of feedings via NGT or OGT over time have been used but the literature is actually inconclusive as to its benefit, and there may be adverse effects especially on gall bladder function.

Concentrating formula so less volume is required to get the same calories is an option. However, this can backfire as the increased caloric density can actually create GI discomfort in preterms.

Change in formula to Gentle or Sensitive formulas (Enfamil Gentle Ease, Similac Sensitive, Good Start Gentle), low lactose formula (Similac Spit Up, Gerber Good Start), possibly Soy based formula (if tolerance to cow milk protein is in question), possibly Extensively Hydrolyzed formulas in which proteins are mostly broken down (Nutramigen, Alimentum, Pregestimil), or possibly Elemental formulas which contain 100% broken down proteins if suspected milk protein allergy (Neocate, Elecare). Such decisions may be made with GI or by neonatology alone.

Imaging typically starts with and UGI to look at structural integrity and if the structures are in proper rotation. An UGI is not a test for reflux; radiologists will tell you that if they do not capture reflux in the moment in radiology, that does not mean the infant does not reflux, but if they DO capture reflux on an UGI, it is such a brief and minimal volume procedure that reflux is likely a key issue for that infant. While other types of imaging are possible in a workup for GERD/EERD (Ph probe studies, reflux scans, MII), they are not typical in the NICU.

A swallow study would not be a test to assess for reflux though we may capture EER as an incidental finding during an instrumental assessment of swallowing physiology.

So, as you can see the neonatologists must weigh so many critical factors. Work with your team and their thinking, be present and learn their rationales, read the research they are discussing, contribute what you can, especially clinical interventions that are often first line. There is an evolving science and practice and being part of the team is ho we both learn and add value.

I hope this is helpful. See Dupont, C. (2017). Gastroesophageal Reflux (GER) in the Preterm Baby. In Gastroesophageal Reflux in Children (pp. 111-124). Springer. It is quite informative though there are multiple other articles. DOI

I hope this is helpful.


Research Corner: Sensory Processing Disorders and Former Preterms

Researchers at Washington University in St. Louis conducted a study to describe the incidence of sensory processing disorder in former preterm infants at age 4-6 years. They also sought to define medical and socioeconomic factors associated with sensory processing disorder and examine relationships between neurobehavior at term and later sensory processing disorder. The study enrolled thirty-two preterm infants born <30 weeks and conducted neurobehavioral assessment using the NICU Network Neurobehavioral Scale (NNNS) at term equivalent age, and the Sensory Processing Assessment for Young Children (SPA) at 4-6 years of age.

In this sample, 50% of children presented with a sensory processing disorder at age 4-6 years based on SPA scores. Additionally, the study did not identify any association between sensory processing disorder and medical and socioeconomic factors including gestational age at birth, sex, cerebral injury, presence of NEC or PDA, amount of respiratory support, days on TPN, surgeries, race, type of insurance, maternal age at birth, and maternal marital status. They did, however, find that more sub-optimal reflexes, and more signs of stress on the NNNS at term equivalent age was associated with having a sensory processing disorder at age 4-6 years.

The authors discuss the role of the NICU environment on the developing sensory system of the preterm infant, noting that sensory development begins in utero, but must continue to develop in the NICU, where their sensory systems can be bombarded with stimuli for which they are not developmentally prepared. They also note “it is unclear whether these early markers are indicative of the impairment that followed, or if the early impairment identified on the neurobehavioral exam resulted in altered sensory experiences, leading to subsequent sensory processing disorder.” This study demonstrates that standardized neurobehavioral testing can help identify those infants most at risk for sensory processing disorder in childhood.

Ryckman, J., Hilton, C., Rogers, C., & Pineda, R. (2017). Sensory processing disorder in preterm infants during early childhood and relationships to early neurobehavior. Early Human Development, 113, 18-22.