Problem-Solving: Pacifiers in the NICU and Aversions


I’m wondering if you have any insight into this. Despite developmental care and a good general awareness of feeding issues that may come down the road, we’ve had a group of chronic babies (<28 weeks at birth, long respiratory course- still on HFNC at 38+ weeks) that go from loving their pacifiers to gagging on them. Of course, it’s not surprising that these chronic, sick babies with arduous courses don’t want their pacifiers (or anything for that matter) in/near their mouths. Is there anything to do earlier in the course to prevent this? Besides developmental care/kangaroo care/making oral experiences as positive as possible/stopping with gagging. Some nurses are asking if we should avoid pacifiers earlier on in the course? Start therapy earlier? I don’t typically intervene in these kids earlier besides education for staff on developmental/kangaroo care (but do see them once stable respiratory wise and we’re thinking about nipple feeding to help guide readiness/nipple selection). Any thoughts? My gut is that we just to be extra vigilant about making sure the baby is ready/looking for/accepting the pacifier and tolerating it all along, encouraging skin to skin vs. actual interventions, but would love your input. Thanks as always for your expertise with these little ones!



You are such a critical thinker. They are so lucky to have you! It’s not the pacifier but rather most likely how the nurses may be inadvertently “giving it” to the infant.

I encourage infant-guided offering of the pacifier when the infant is able from a respiratory and GI perspective to accept it.

That means we need to use the infant’s communication to thoughtfully guide us.

Infant-guided neuroprotective offering of a pacifier means using the infant’s rooting response (by gently moving the pacifier across the infant’s lips) and then honoring the infant’s response. If WOB and/or RR is increased, the infant may not open his mouth and is saying “Not right now. I need to breathe; please wait and ask me again in a little while.”   Too often, caregivers mistake the infant’s not opening his mouth as an indication to just “place the pacifier” or “put the pacifier in”. But it is typically not lack of skill why he doesn’t take the pacifier, but rather he is purposefully not rooting to say, “not right now”. It is an adaptive/compensatory behavior whose meaning may be misinterpreted or misunderstood by some caregivers, especially those who are task -oriented versus infant-guided. GI discomfort may lead to the same response from the infant. Imagine being “asked/expected/”forced” to suck on a pacifier when don’t feel good in your GI system. The infant will remember how he felt. Good intentions to give a pacifier can inadvertently create negative experience.

When caregivers bypass this communication, motor mapping in the brain for the root-to-latch sequence will be altered and maladaptive behaviors can result.

Gagging, grimacing, pushing the pacifier out are all overt refusal behaviors. They look very different then “engagement” behaviors of rooting and focused attention. It really isn’t rocket science.

Perhaps even more worrisome is the stress created by being asked/expected/”forced” to do something that does not feel good right then.

The stress that results, like all NICU stress, has the potential to increase cortisol, change via the amygdala along the HP-axis, and change the architecture of the brain.

This is the pathway to learned refusal behaviors and learning to “hate” the pacifier.

The infant’s communication matters, as does every early experience using his mouth. Neuroprotection can be supported via an infant-guided approach to feeding readiness as well as feeding.



Shaker, C. S. (2018). ‘Mom, You Got This’: Feeding is communication. When we help NICU caregivers interpret what their preemie is telling them during feeding, we support the parent-infant relationship. The ASHA Leader, 23(10), 54-60.

Shaker, C. S. (2017, April). Infant-guided, co-regulated feeding in the neonatal intensive care unit. Part I: Theoretical underpinnings for neuroprotection and safety. In Seminars in speech and language (Vol. 38, No. 02, pp. 096-105). Thieme Medical Publishers.

Shaker, C. S. (2017, April). Infant-guided, co-regulated feeding in the neonatal intensive care unit. Part II: Interventions to promote neuroprotection and safety. In Seminars in speech and language (Vol. 38, No. 02, pp. 106-115). Thieme Medical Publishers.

Shaker, C. (2013). Reading the Feeding: The amount of milk a preemie drinks largely determines readiness for discharge from the neonatal intensive care unit. But just because an infant feeds well today doesn’t mean it will last. In the long term, fostering a child’s consistent, positive response to feeding may be more important. The ASHA Leader, 18(2), 42-47.

I hope this is helpful.


Problem-Solving: Enzymes in EBM that affect thickening


I am currently working in a Level 3 NICU and needing to thicken a baby’s formula to nectar. Baby was previously on fortified breastmilk, but I remember you saying at your course that breastmilk and oatmeal don’t bond. The neonatologist would like evidence. Do you have any suggestions where I can find this info?


It’s likely the Amylase (see below) — while its function when there is purely EBM from the breast is perfect, when additives for thickening are introduced in the EBM, it inhibits binding with oatmeal or rice cereal with the EBM. The oats and the EBM stay separated and therefore the EBM is not thickened.

See Enzymes Found in Breast Milk

There are many different enzymes found in breastmilk. These enzymes play an important role in the health and development of a newborn child. The enzymes in breast milk serve a variety of functions, some of which we do not even know yet. Some enzymes are necessary for the function of the breasts and the production of breast milk, some enzymes help a baby with digestion, and some are essential for a child’s development. Here are the most important enzymes found in breast milk.


Amylase is the main polysaccharide-digesting enzyme. It digests starch. Since babies are born with only a small amount of amylase, they can get this essential digestive enzyme through breast milk.


Newborns can fully digest and use the fat in breast milk because of lipase. Lipase breaks down milk fat and separates it into free fatty acids and glycerol. Newborns get energy from free fatty acids, and lipase makes those free fatty acids available before digestion occurs in the intestines.

Lipase is also responsible for the soapy, metallic smell that refrigerated or previously frozen and thawed breastmilk sometimes has. The cold temperatures and freezing and thawing of breast milk high in lipase can cause the fat in the milk to break down quickly leaving an unpleasant odor. It may not smell good, but the nutritional value is still good.


Protease speeds up the breakdown of proteins. There are high levels of protease in breast milk. It is believed that this enzyme is important for digestion especially during the period right after birth.


Lactoferrin is an iron-binding protein. It helps a baby absorb iron. Also, along with white cells and antibodies, lactoferrin kills bacteria. Lactoferrin stops E. coli from attaching to cells and helps to prevent infant diarrhea. Lactoferrin also prevents the growth of Candida albicans, a fungus. Lactoferrin levels are very high in preterm breast milk and the levels go down as lactation continues.


Lysozyme protects an infant against bacteria such as E. coli and Salmonella. The levels of lysozyme in the breastmilk rise especially around the time babies begin eating solid foods. The increase in lysozyme helps to protect children from germs that can cause illness and diarrhea.

I hope this is helpful.

Problem-Solving: Offering Tastes on NCPAP

Question: I am a Registered Nurse in a regional NICU where we take care of level 2, 3 and 4 infants. I am also co-chair of our dysphagia committee. We are currently doing a swallowing therapy-Therapeutic tastings. The current protocol allows therapeutic tastings to be done with our premature infants > 32 weeks adjusted gestational age that are on respiratory support as high as nasal cpap of 5 cm H2O. These tastings involve small volumes (0.05-0.1ml) of the infants current feeding administered to an infant using a syringe and adapter while infant is sucking on a pacifier, pumped breast or finger. The therapeutic tastings can be ordered to be administered 0.05-0.1 ml every 30 seconds up to a total of 2 ml TID by SLP, nursing staff or parent. Our medical team recently asked the dysphagia committee if it would be safe to do therapeutic tastings on infants that are on respiratory support higher than nasal cpap of 5 cm H2O (not including intubated infants). Is there any research supporting or disputing doing swallowing therapy such as our therapeutic tastings with an infant on respiratory support > nasal cpap of 5 cm H2O?


This question is not answered currently in the literature,  so,  as you have alluded to, caution and critical reflective thinking are essential.

Of course current level of respiratory support required is only one piece of the equation, as GA and other co-existing co-morbidities, WOB, respiratory history (arduous versus non-arduous course) are some key considerations that will affect risk to invade the airway, create undue stress that may adversely affect neuroprotection, and potentially then lead to maladaptive behaviors and aversions.

Take a look at Louisa Ferrara’s paper ( Bidiwala, A. A., Ferrara, L., Islam, S., Pirzada, M., Barlev, D., Sher, I., & Hanna, N. (2016). NEWS FROM THE NICU AND PICU: Effect Of Nasal Continuous Positive Airway Pressure (ncpap) On The Pharyngeal Swallow In Neonates. American Journal of Respiratory and Critical Care Medicine, 193, 1.

Results suggested that the driving force/flow under CPAP appeared to predispose infants to aspiration under fluoroscopy. I wonder if true pacifier dips — via droplet of EBM on pacifier tip— versus using a syringe where bolus size or speed of bolus delivery cannot be as readily controlled — would be a better option. That is what I prefer when the infant appears ready from multiple perspectives to initiate tiny tastes. It offers cautious opportunities for purposeful swallows but with a greater safety margin.

Due to the fragile nature of a premie requiring CPAP, I would have parents not deliver tastes but rather have parents learn along with the SLP or RN —how to recognize respiratory stress cues at baseline and with tastes, state modulation baseline and changes, swallowing behaviors (both audible and visible), postural/sensory-motor baseline and changes, signs of disengagement both subtle and more overt ——while the SLP or RN offers  the tastes and uses anticipatory guidance to explain what infant is communicating.    The complexity of what we are asking the infant to do clearly requires “in the moment” immediate infant-guided responses from the caregiver to optimize safety.  It is worrisome to expect parents to recruit the level of clinical reasoning required in these uncharted waters, as it is with the first PO feeding.  I find parents typically benefit from, and appreciate, learning along with the caregiver to build understanding of the multiple “avenues” of preterm infant communication during tastes as well as future PO experiences.  See Shaker, C. S. (2018). ‘Mom, You Got This’: Feeding is communication. When we help NICU caregivers interpret what their preemie is telling them during feeding, we support the parent-infant relationship. The ASHA Leader, 23(10), 54-60.

Offerings that are arbitrarily every 30 seconds perhaps may not take into account the infant’s ability or desire to continue. Alternatively, infant-guided offerings would best utilize infant communication from moment to moment to determine when an infant may be ready for another tiny taste.

I hope this is helpful.

Research Corner: Aspiration and Dysphagia in the Neonatal Patient

Aspiration and Dysphagia in the Neonatal Patient

Nikhila Raol, Thomas Schrepfer, Christopher Hartnick,

Clinics in Perinatology 45 (2018) 645–660



_ Management of neonatal dysphagia and aspiration should involve a multidisciplinary  effort, including neonatologists, otolaryngologists, pulmonologists, gastroenterologists, and speech-language pathologists.

_ Flexible fiberoptic laryngoscopy and a formal swallow evaluation in conjunction with the speech pathologist should be undertaken in any neonatal patient with dysphagia.

_ Babies born before 34 weeks may have dysphagia owing to a developmental delay.

_ Although the otolaryngologist may recommend acid suppression in patients with laryngomalacia, there is a lack of evidence to support use of acid suppression medications in suspected extraesophageal reflux disease.

_ Addressing anatomic/structural causes of aspiration are indicated when present; however, the vast majority are nonanatomic.




Shaker Seminars 2019

Catherine Shaker Seminars – 2019

 May 2019: Wilmington DE – Nemours Children’s Hospital

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

June 2019: to be announced

July 2019: To be announced

August 2019: Indianapolis, IN   Eskenazi Health

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

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

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

 October 2019   Columbus, OH   Nationwide Children’s Hospital

  • October10-11 Pediatric Swallowing and Feeding: The Essentials
  • October 12: Pediatric Videoswallow Studies
  • October 13-14: Cue-Based Feeding



Research Corner: Silent aspiration — Who is at risk?

Velayutham, P., Irace, A. L., Kawai, K., Dodrill, P., Perez, J., Londahl, M., … & Rahbar, R. (2017). Silent aspiration: Who is at risk?. The Laryngoscope.

Among 1,286 patients who underwent MBS, 440 (34%) demonstrated aspiration. Within the aspiration group, 393 (89%) specifically demonstrated silent aspiration. Thin fluids were silently aspirated in 81% of these patients. Of children aged <6 months, 41% were found to aspirate and, of those, 95% silently aspirated. Median age at which patients demonstrated silent aspiration was 1.1 years. Silent aspiration was documented in 41% of patients with laryngeal cleft, 41% of patients with laryngomalacia, and 54% of patients with unilateral vocal fold paralysis. Laryngeal cleft, laryngomalacia, unilateral vocal fold paralysis, developmental delay, epilepsy/seizures, syndrome, and congenital heart disease were all associated with silent aspiration.

Their conclusions: Silent aspiration may be associated with several underlying conditions and is more common than previously described. Caregivers and clinicians should be aware that the absence of cough does not eliminate the possibility of aspiration. Modified barium swallow studies can reveal silent aspiration, which is difficult to detect on clinical feeding evaluation. Modified barium swallow findings can guide feeding therapy and the overall management of aspiration.

Read more….


Research Corner: Quality Improvement Initiatives Related to Cue-Based Feeding in Preterm Infants

Fry, T. J., Marfurt, S., & Wengier, S. (2018). Systematic Review of Quality Improvement Initiatives Related to Cue-Based Feeding in Preterm Infants. Nursing for women’s health.

A nursing team at The Children’s Hospital, OU Medicine, in Oklahoma City, OK examined and synthesized the outcomes of quality improvement (QI) initiatives related to cue-based feeding of preterm infants to facilitate implementation of findings to improve nursing practice.

Their review yielded seven studies related to cue-based feeding of preterm infants. Five studies included multidisciplinary stakeholder teams to assess their respective NICU environments and facilitate project completion. In two studies, feeding “champions” were designated as facilitators. In one study, researchers used a Plan–Do–Study–Act approach and emphasized process over outcome. In six studies, researchers measured hospital length of stay, which decreased in five intervention groups. In three studies, researchers measured infant weight gain, which increased in two intervention groups. In two studies, researchers monitored weight gain velocity, and in five studies, researchers reported earlier attainment of full oral feedings.

They concluded: Weight gain, time to full oral feedings, and hospital length of stay may be improved with the use of cue-based feeding. QI initiatives are a practical means to bring best evidence and multidisciplinary collaboration to the NICU.



Problem-Solving: Stridor in Newborn Requiring NICU Care

Problem-Solving: Stridor in Newborn Requiring NICU Care


We have an infant in our NICU who is presenting with stridor during inhalation and congested/loud breathing on what appears to be during exhalation. I have found with some infants demonstrating stridor they won’t have that congested sound to them, but others will. I asked one of our 38-year veteran nurses and she said she has found the same thing; some will have the congested/loud breathing sound and others won’t. We also do not have ENT’s in house so those that we find have stridor are RARELY sent out for it and we never get to see a report if an infant is seen in out-patient what the findings are. I feel my area of expertise is lacking in this area and would love some more guidance and education on the topic. My question is: Is this typical and if it is what is the reason for the different sound?


Sounds like you are describing inspiratory stridor. Can have varying etiologies, such as EER/LPR, laryngomalacia. Generally reflects a level of obstruction of the upper airway. The worry is that, with dynamic sucking, swallowing and breathing, it is not uncommon for the etiology/alterations related to the stridor to increase risk for airway invasion during PO feeding. With this clinical presentation, many physicians do not consult ENT, unfortunately, and assume its ok to just wait it out without knowing what’s causing the stridor. They perhaps due not understand the possible functional and safety implications.

In my experience, a clinical swallowing evaluation followed by an ENT consult/flexible scope at bedside can guide us to etiology, reinforce the need for a videoswallow study to objectify impact on physiology and likely interventions. The ENT may see reddened larynx or cords, altered airway structures that are known to adversely affect swallowing physiology.

Many infants with stridor mis-direct the bolus from below or above in my experience. The co-occurring congestion suggests either saliva/refluxate in the hypopharynx and/or laryngeal inlet (may be related to EER) and/or saliva (may be also related to EER and or poor swallowing), if congestion heard at rest. If congestion with PO, suggests potentially a mis-directed toward/above/in the airway. May be a combination of both.

Without hearing the infant, I am at a loss but loud breathing on exhalation suggests perhaps prolonged exhalation which may he be using to try to re-open the collapsing airway and/or to open the alveoli and add PEEP if there’s indeed some airway obstruction, or his trying to clear the congested material off the vocal cords or out of the supraglottic space perhaps. Just hypothesizing.

Other co-morbidities if present need to be correlated, though this may be an “isolated” altered airway problem. I use the quotes around “isolated” as it really is never truly isolated since it is part of a dynamic system (the swallow).  Could also be an additional component of lower airway alteration (tracheal/bronchial). ENT sounds essential to elucidate the integrity of the airway to assist you in your differential.

Clinical problem-solving is my passion. That’s why I developed my 2-day Advanced Pediatric Dysphagia seminar which will be offered again in 2019!

New Shaker Publication – “You Got This Mom” – in the American Speech-Language Hearing Association (ASHA) Leader

New Shaker Publication – “You Got This Mom” – in the American Speech-Language Hearing Association (ASHA) Leader

Feeding is Communication. When we help NICU caregivers  interpret what their preemie is telling them during feeding, we support the parent-infant relationship.

Excerpt: ” What builds confidence is shifting the focus to feeding quality and their relationship with their infant. We get there by helping parents conceptualize feeding as a “conversation” with their infant. Our role as feeding specialists in the neonatal intensive care unit (NICU) is to guide parents to develop this “co-regulation” with their infant—this line of communication that drives feeding, and, ultimately, the parent-infant relationship itself. With our ongoing support, parents can begin to see their relationship with their infant as the foundation for feeding. Intake is then viewed as the byproduct of a quality feeding interaction, not the feeding’s only goal. And so, the parent-infant-relationship begins, through infant-guided feeding.”

Read more ………

Follow the link below to the full article on the ASHA Website.




Problem-Solving: Feeding on NCPAP and HFNC in NICU


I have had an incredibly difficult time navigating our neonatologists. I gave a detailed presentation to our medical director and other various NICU staff members regarding feeding expectations for our infants on prolonged or increased respiratory support (specifically HFNC over 2 liters). Obviously, these infants are complex and their readiness to engage in bottle feeding can not be perceived as identical to one another. However, much to my dismay, we now have a policy set in place that we will attempt po bottle feeding on infants who are on HFNC 4L or less. Obviously, my assessment is involved, but not always taken seriously. I was provided this document to refute my claims: Effects of Nasal Continuous Positive Airway Pressure and High-Flow Nasal Cannula on Sucking, Swallowing, and Breathing during Bottle-Feeding in Lambs. Additionally, the neonatologists seem to only accept evidence provided by a physician and/or a Cochrane review. I have continuously brought up ‘no evidence of harm’ is not the same as ‘evidence of safety.’ I am fortunate to receive standing orders on all admits to our NICU, further encouraging a preventative approach with all admitted infants. Since the criteria to be a level 3 NICU must involve therapy services, I often feel as if my impressions are just a ‘check off the list’ and the providers will sometimes instruct the staff to bottle feed infants who are not appropriate candidates. Providers also still believe that there is a ‘critical window’ that infants must engage in po feeding within a certain time frame. I know this is not factual but I am not able to move our physicians away from this thought process! We have taken short strides forward and I have fought, and I am continuing to fight, very hard to protect our fragile infants and demonstrate my worth. Unfortunately, I do feel as if getting the infant discharged as soon as the provider deems appropriate, despite difficulties with po feeding, is a driving force. It is almost as if the infant’s problems are pushed onto the pediatrician. I understand that physicians must experience pressure to discharge infants secondary to changes in our healthcare culture. I know I am not alone in this battle and that other therapists must share similar experiences as well as similar feelings. I am taking small steps forward in forging positive relationships with our providers. Any advice would be greatly appreciated!

There are a handful of pertinent articles accessible via a search. One done on the effect of NCPAP under videofluoroscopy, was done by Louisa Ferrara and her NICU colleagues in NY. Their preliminary results were so worrisome that the neonatologists stopped the study.

Unfortunately, often the conclusion regarding the “safety” and the “tolerance” of NICU infants feeding on NCPAP is determined by volume and perhaps lack of overt or symptomatic decompensation. This study will hopefully re-direct thinking about the impact of the The study determined that “Oral feeding while on NCPAP significantly increases the risk of laryngeal penetration and tracheal aspiration events,” and recommended caution when initiating oral feedings on NCPAP. The conclusions, unfortunately, did not focus on changes in swallowing physiology under NCPAP, which would have been instructive. It  is not only aspiration that is worrisome but also untoward effects on physiology that increase risk for airway invasion.

My experience in the NICU suggests that, even for those infants who do not frankly penetrate or aspirate under NCPAP in the “moment” in radiology, we are likely to see adverse effects on swallowing physiology. That, for me, is the most compelling takeaway from this study. Bonnie Martin-Harris has taught us that aspiration or penetration is neither sufficient nor necessary for a swallowing impairment – meaning that our focus needs to be on physiology, because impaired or altered physiology and its etiology(ies) create the conditions under which bolus mis-direction can or does occur.

It is not uncommon for neonates to evidence changes in swallowing physiology due to respiratory co-morbidities, even when stable on less support or indeed on unassisted room air. With infants requiring NCPAP or HHFNC, our assessment of risk related to PO feeding or not PO feeding must consider many factors beyond level of respiratory support required.

This is a practice dilemma for all NICU SLPs. The pressure to get infants out of the NICU often drives care decisions, especially when it comes to PO feeding.

Many neonatologists incorrectly assume that there is a window within which our preterms must “experience” PO feeding or they will “miss that critical window and never learn”. So, despite co-morbidities and often respiratory needs that are paramount, infants are being asked to feed. That well-intentioned paradigm is based on writings from Gesell back in the 60s that talked about a “critical window” for learning to eat. Those times were different in many ways as was the population being described. Early intervention is now a standard of care in NICUs to support readiness. Our goal is for neonatal care that is neuro-protective and promotes positive overcomes, and recognition of safety issues inherent in the complex task of PO feeding even when weaned from CPAP and HFNC —they clearly call for reconsideration of that paradigm, which, perhaps to a large part, underlies the thinking that leads to “pushing PO” and orders to PO on CPAP and HFNC. Many of our former preterms do indeed learn to feed orally when respiratory co-morbidities better permit, once weaned, and from my experience, do so with much less stress and much more safely.

Advocating for safety for these infants is a critical one for SLPs in the NICU and PICU. Current NICU technology has advanced to the point that more infants are surviving and yet many are requiring extended periods of CPAP and HFNC. Many extremely preterm infants in our NICU with CLD at post-term (41 weeks PMA +) remain dependent on CPAP or HFNC. My NICU team has had good collaborative conversations about the benefits of ST being involved to maintain a positive oral-sensory environment, promoting the oral-sensory-motor components that are the underpinnings for future PO feeding, beginning early to foreshadow for parents the swallowing, breathing and postural skills needed, and helping families also support those components, versus attempting PO feeding when the infant clearly is struggling with respiratory stability. Clearly, medical co-morbidities predispose an infant in the NICU to PO feeding problems. Multiple papers have studied that. Those infants with the greatest respiratory comorbidities, often those born < 28 weeks’ gestation and BW < 1000 grams, are most likely to require CPAP and/or HFNC at those post-menstrual ages when PO feeding is often attempted. Sick newborns may also present similar issues, secondary to their co-morbidities.

If the infant has such respiratory needs that he requires CPAP, or a HFNC, one must ask if PO feeding is really a priority for that infant at that time. The ability to reconfigure the pharynx from a respiratory tract and back to an alimentary tract with precise timing and coordination surrounding each swallow is a concern. When we look objectively in radiology during an instrumental assessment of swallowing physiology, even infants with CLD stable on RA have altered or impaired swallowing physiology as a direct result of their CLD. The bolus mis-direction and resulting aspiration we often observe is typically silent. In the adult population in the most recent information I have seen (Garon et al, 2009 Journal of Neuroscience Nursing) reported that of 2000 adults studied with a variety of co-morbid conditions, including COPD, 54.5% of those who aspirated did so silently. The data I have collected thus far for NICU infants suggests strongly to me that even the data from Arvedson et al in 1994 likely dose not capture the risk for our current population of infants to silently aspirate; her study population was not only less involved from a respiratory perspective back in 1994 than the population we see today, but it also was a population composed of not just infants.

The need for an “urgent breath” often can predispose an infant with increased work of breathing to silently mis-direct the bolus into the airway during the swallow. The ability of the infant to close the glottis against the driving force of the respiratory support, while breathing with increased effort or with an increased respiratory rate, which effectively creates air hunger, and yet still maintain glottic closure throughout the duration of the swallow, would likely be precarious. Given the infant’s likelihood of baseline tachypnea and increased WOB, the dynamic adjustments of the airway surrounding the swallow are likely to be disrupted and create uncoupling of swallowing and breathing. Without objective data on the impact of CPAP or HFNC on swallowing physiology we cannot conclude that feeding under these conditions is “safe”. Indeed, infants for whom we do not necessarily witness aspiration during a dynamic swallow study, may indeed show alterations in swallowing physiology that may indeed predispose them to airway invasion under “the right conditions” during PO feeding (changes in nipple flow, changes in position, changes in respiratory support, sucking rate/length, timeliness and depth of breathing pauses for example) so it isn’t even just about aspiration but the potential impact of CPAP and HFNC on swallowing physiology. The fact that the infants “eat” and “are fed” and “transferred volume” does not equate to “safe feeding”.

We must of course consider the physiologic stress likely to occur when the infant experiences “feeding” when they still require NCPAP and or HFNC. It is highly possible the stress of trying to breathe and coordinate a swallow may lay down neural pathways that move the infant away from wanting to eat, by wiring those sensory-motor pathways that lead to current and/or future maladaptive feeding behaviors. We know that studies looking at stress in preterms have shown an association with adverse changes in brain structure on MRIs.

In the NICU seminars I teach, this body of evidence and our dilemma are always part of our problem-solving discussions. I am fortunate after 33 years in the NICU to be part of a team that is trying to look beyond “getting them to eat” and learning to partner with ST to guide practice while the evidence-base is emerging. NICU SLPs are in a key role to dialogue, problem-solve and focus on safety and neuroprotection as essential part of this practice issue which confronts every neonatal team.

Jim Coyle has said: “There is one rule of thumb: there is no single parameter that qualifies or disqualifies a patient for anything or that confirms or refutes risk in and of itself. It is the combination of parameters that the clinician uses to estimate risk and to form a diagnostic impression and complete a differential. That is what we teach students and trained clinicians should be emphasizing. Grab your water bottle and go for a 2-3-mile run. After 15 minutes when at your aerobic steady state and RR is up, try to take a drink of water and observe what you need to do to orchestrate the whole thing. Yet you are healthy and mature and not recovering from respiratory issues. Very illuminating.”

The dialogue needs to continue, and we need measures of oral feeding that go beyond intake, and methods of assessment that capture critical variables, including objective assessment of physiology. And so, we remain in the “gray zone” as I like to call it, where there are more questions than answers, which is where most NICU therapists live. We must therefore consider theoretical constructs related to neonatal swallowing, continue to search for the evidence, use critical reflective thinking and dialogue with our neonatal colleagues.

I hope this is helpful.




Scholarship Opportunity: Winner announced!

Dr. Brown’s® Medical recently offered a unique educational opportunity. The “Scholarship Opportunity” was for one individual to attend a week long, three course Catherine Shaker seminar.

Congratulations to Lydia Coley, recipient of The Dr. Brown’s Scholarship to attend the Austin 2018 Shaker Seminars.

With her permission, I am sharing part of her application statement:

“When your heart is all in, experiences vacillate on a pendulum from extreme satisfaction and fulfillment to disheartenment – the latter driving the questions what can change. Illustrating the dichotomy is the family who is receptive to supporting their infant based on a comprehensive team approach where infant and family are the center of care, versus care that leaves any party feeling alienated, conflicted, or dissatisfied. As pediatric practitioners, we’re charged with serving our patients and families in a holistic manner. This means using our hearts to drive ongoing continuous improvements within ourselves, our practices, and our communities, so that each and every experience is optimal.

Clinically, each experience contributes to ongoing change as an opportunity for improvement. I’ve been offered the opportunity to support a medically complex infant in a well-established intensive care unit where all the resources are available, to see how those recommendations evolve when going home to limited resources, to now participating in an environment where clinical resources are emerging–resources of tools, objective measures, literature, clinical research, continuing education, products, family services, and new ways of facilitating collaborative care support personal clinical growth and the services I can provide to my patient, family, team, and extended clinical family.

The more I learn the more I’m inspired by how much more there is to learn!”

Lydia’s message reflects a passion for learning that inspires clinical excellence.                        Congratulations, Lydia!

Research Corner: Resources for your professional library

These are two wonderful resources to add to your professional library!

Feed Your Baby and Toddler Right: Early eating and drinking skills encourage the best development

Book by Diane Bahr MS CCC-SLP CIMI     Published: 2018


Functional Assessment & Remediation of Tethered Oral Tissues (TOTs)

Book by Robyn Merkel-Walsh and Lori Overland      Published: 2018

I hope you enjoy them as much I have!


Problem-Solving: PO feeding post extubation in the NICU


What are your current practices regarding oral feeding infants who have been recently extubated? Understandably, these infants typically don’t cue well for a period, continue to demonstrate respiratory complications, but are often asked by providers to attempt oral trials/nippling before the infant is truly ready. Please understand that I am aware that every assessment should be individualized, and we should first take into consideration how the infant tolerates handling, NNS, etc. However, since I have spent time in adult acute care, I do not complete a swallow assessment in this population until 24 hours post extubation. Delaying swallow evaluations until 24 hours after extubation would aid in improved reduction of laryngeal edema and improved vocal quality, return of pharyngeal/laryngeal sensation, improves breathing, with an overall improvement in medical stability. It is also known that infants are at a much higher risk for silent aspiration. Do you apply these principles to our fragile infants in the NICU? I am searching for more support regarding why not pushing these babies, who may have even delivered to term but were recently intubated/extubated, is so vital for their developmental outcomes. Thank you for any support!


I work in a large level IV NICU, so we see the sickest and most fragile preterms, some of those born at 22 weeks. Intubation and ventilation are avoided as much as possible, with many infants being stabilized on NIPPV or CPAP in the delivery room.

Those NICU infants who are intubated, once extubated, often require levels of respiratory support that continue to delay PO feeding. Unlike adult ICU, it is uncommon in NICU to be consulted on an infant recently extubated (within 24 hours) who now has orders to PO feed. Though it can happen, unfortunately.

Once an infant is stable on NIPPV, we will be consulted to begin support towards/readiness for oral feeding. That is great because we are part of the decisions going forward then. Even sick newborns recently extubated will often have sequelae, especially respiratory (but also perhaps neuro, GI, airway, cardiac and/or neuromotor) that create risk for airway invasion with expectations of early PO feeding. This is not always appreciated by the NICU medical team, despite their best of intentions, i.e., “lets’ get him feeding” so “he can get home”. Part of your role will be protecting these infants from good intentions gone awry through collegial conservation, bringing the research about feeding outcomes and neuroprotection, and co-morbidities that create inherent risk for bolus mis-direction.

I like to conceptualize the feeding-related services we provide in the NICU as “feeding readiness” and “supporting safe/functional PO feeding” to help neonatal nurses and neonatologists better understand not only the value we add to the NICU team, but also that learning to feed orally is not a “light bulb” moment – i.e., it’s not that all of a sudden the infant is ready . Unfortunately, well-intentioned but ill-timed, too early, stressful PO 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 also impacts the infant-parent relationship and multiple domains.

As you know, sick newborns who required intubation and ventilation cannot just bounce back, once extubated. The reasons for requiring intubation often have sequelae that adversely affect PO feeding. Fragile preterms 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

All NICU infants need supportive infant-guided learning experiences outside of the uterus. These should most closely align with the ideal sensory-motor environment (intrauterine), and early extrauterine environment of the healthy term infant. Our challenge is to help caregivers embrace the critical importance of this step in the process toward PO feeding, whether a preterm or a sick newborn.

Prior to PO feeding, the benefits of mother’s milk (EBM) to the mucosa via tiny trace droplets to promote purposeful swallows and oral-sensory-motor mapping primes the sensory-motor system along of the preterm infant or sick newborn, as can nuzzling at the breast (kangaroo mother care). The key is that 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. This may not fit the time line set to “get them feeding”. 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.

Neonatologists may push PO to get them PO feeding, let them “practice”. 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 preterm’s immature emerging neuronal pathways and oral-sensory-motor system, or the sick newborn’s altered systems. This must be considered in the context of that infant’s co-morbidities and the impact of those co-morbidities on the dynamic swallow. 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 for all NICU infants.

I teach these concepts and their underpinnings in my NICU seminar, cite relevant research and clinical wisdom to help us have conversations with our NICU colleagues. Our goal is always to promote infant guided feeding and neuroprotection. The NICU is not an easy place to work, as passions and medical fragility run high. Every day l have conversations that require me to think deeply, be kind and patient but advocate for the infant. Along the way I have built relationships with neonatologists and nurses that create the opportunity for respectful conversations even when we disagree. As you continue to build relationships with your NICU team, focus on bringing the relevant research, having collegial conversations, and thinking along with nurses and neonatologists both during Rounds and during your sessions. That opens the door for changing the feeding culture, one day at a time.


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.