Problem-Solving: Stridor in preterm infant with trouble breastfeeding


I am seeing a 5 week old tomorrow morning, born at 35 weeks. I will be looking at fat pads and tethered oral tissues. Mom reports breastfeeding is very painful. Mom just sent a video and I am hearing a lot of stridor.  I am also seeing a very shallow latch. we will explore a Dancer hold tomorrow as well. I attached a video clip.

Thoughts on the stridor?


ENT is a very important consult for which to advocate. I have been fortunate over the years to be mentored by some fabulous neonatologists (who love the airway like I do!), RTs, pulmonologists and pediatric ENTs who have kindly allowed me to ask a million questions and who kindly have helped me think about the airway from their perspectives — but very “simplified” so I could start to make sense out of what  I am seeing and hearing clinically.

We don’t know much about history and co-morbidities for this IUGR-appearing infant except she was 35 weeks GA and is now 40 weeks adjusted age. So much possibility for why we are hearing stridor. Knowing more may assist with our problem-solving on the list serve, and as the SLP seeing the infant, inform a initial differential that allows the SLP to advocate from an informed perspective.

The shallow latch may be purposeful to limit flow in order to protect the airway, or it may be due to tethered oral tissues, or it may be purposeful due to the need to prioritize breathing. Or a combination of any of these etiologies.

Is there apparent mandibular hypoplasia that might be leading to an ineffective tongue-palate seal and poorly controlled bolus? That can lead to stridor.

Be thoughtful with a dancer hold as it will inadvertently increase flow rate, which may not be what the infant wants. If when you offer the dancer hold, you hear increased stridor, or infants pulls away or changes facial expression to a “worried” look, or increases breathing rate or effort, the infant will be “telling you” the dancer hold is not helpful for him right now. Infant guided interventions and the infant’s responses always inform our differential.

Stridor may be iatrogenic (post-extubation, post-ECMO, post PDA ligation or repair to the aortic arch, post-emergent or prolonged or repeated intubation, or due to resulting subglottic stenosis, for example),or it may be congenital (r/t a vascular ring, idiopathic occurrence at birth without explanation, laryngomalacia, tracheomalacia or tracheobronchomalacia). It is surprising  how often it can go apparently unnoticed so to speak prior to our noted concerns, despite worrisome or adverse effects on feeding (intake, co-occurring physiologic stress and apparent swallowing safety). I have seen this both in NICU, PCVICU, and with admissions from home to PICU and our pediatric inpatient units at times over the years.

Cannot tell if the stridor is present at rest, as the video starts when infant is already at breast and sucking.

Cannot see if there are suprasternal and/or supraclavicular refractions present at rest or, if they are seen, are they seen during feeding only.

My mentors have taught me that:
Stridor heard frequently at rest suggests a primary airway pathology. Stridor present at rest often will be exacerbated with the aerobic demands of feeding, both at breast and bottle.

Contrast that with stridor that occurs only during feeding. That may suggest either swallow-breathe incoordination, due to  the tendency to inhale after the swallow, or indeed attempts of the airway to close in a protective maneuver due to bolus mis-direction from above and/or below.

The stridor in the video sounded biphasic, suggesting a fixed airway obstruction (subglottic stenosis, paralyzed vocal cord(s)—as the airflow moves past a constant obstruction on inhalation and on exhalation – that leads to the biphasic stridor.

Contrast that with stridor on only one phase of respiration, which is most typically associated with a dynamic airway problem – i.e., laryngomalacia – stridor is typically only inspiratory, as there is collapse on inhalation   or   tracheomalacia  – stridor is typically heard only on expiration. There may of course be a combination of airway problems, best diagnosed by ENT.

Of course we don’t diagnose airway problems as SLPs. My mentors weren’t trying to teach me to do that, but rather to think critically. I  describe what I hear,  in the setting of that infant’s/child’s unique history and comorbidities, and my ENT and neonatology friends tell me that helps them. And it helps me better consider the “whys” that underlie the feeding and swallowing challenges that result.

I hope this is helpful.

Problem-Solving: Balancing ALARA in radiology with data collection


I’m relatively new to conducting pediatric MBS studies. The pediatric MBS is also a relatively new service provided at our facility. The pediatric radiologist seems extremely conservative in how many swallows/seconds he will allow for an MBS study (10 seconds/swallows total). I was trained at another facility and in talking with my peers, this is not enough swallows to get an accurate picture of an infant’s swallowing (especially if also looking at fatigue, position changes, thickeners).
I’ve been looking for research to support the amount of radiation intensity (continuous) and time (around 60 seconds total) that my peers tend to use, however there seems to be minimal literature that specifically addresses this topic.
Can you advise me as to how to advocate for a more complete study, even though this means more radiation exposure?



Rads are the ones who manage and minimize radiation exposure for patients and us too . So his caution is an attempt to protect us.

ALARA – as little as reasonably achievable – is the mantra. Work with the rad from a perspective of recognizing that and finding a common ground for gathering good data but assuring optimal protection (shielding well, time, distance all matter). Have some conversations outside of the “moment in radiology” to problem-solve.

When I teach my pediatric swallow study seminars across the US, I always survey attendees for average exposure times they use as guides, and they are typically <2 minutes for infants , and < 5 minutes for children.

This allow typically for enough data to objectify physiology and interventions usually.

If I need to watch a bit longer to complete my differential, I let the rad know and ask if we can watch just briefly and he knows I really need to see that but that I am careful to watch exposure time.

Our aim is the least dose, so if I use about more time it is only after careful thinking and when it is crucial data that is needed.

Our tech can tell us at any time the exposure time up to that point, so we know how we ear doing as we go along. Tech tells us total exposure time at the end, and I always ask myself is there anything I might have done differently to lessen the exposure time.

Usually there is not but I always try to consider that question so can become a better clinician.

Rads usually pulse the beam, we use 30 frames per second but not every hospital radiology team does. Studies have shown that less frames/sec results in less useful data and 30 fps is optimal.

If the rad pulses the beam, and he starts the beam when you say “on” , and you plan what you are going to observe to objectify physiology, carefully select interventions to objectify so you minimize radiation, then these exposure time guidelines work well.

Feeding off line for fatigue while eating/drinking materials impregnated with barium will not use up that exposure time, just the brief re-imaging post fatigue feeding , to see if there are traces in the airway , larynx, nasal airway, etc. that suggest bolus mis-direction and or residue when infant/child was feeding off line, simulating fatigue factor.

Try this approach and see if it works. It does for me.  I developed it with input from our rads, who problem-solve with us as a team and we learn from each other from a place of mutual respect for the perspectives we each bring. The rads  recognize we too will do all we can to assure safety and focus on  ALARA.

I hope this is helpful.

Problem-Solving: 3 y/o with Polymicrogyria


I have a family with 3yr old son dx- polymicrogyria. During current hospitalization, treatment team is recommending NG tube and NPO. He will be sent home with this in place at least 4-8 weeks. We have been working on feeding/swallowing for several months now. My question is, how detrimental to current feeding and swallowing goals is this long term NG tune placement? Should the family receive more counseling regarding PEG prior to returning home (they are in a city, 12 hours from our rural location). I don’t want NG to result in increased risk of aspiration of reflux or hinder oral feeding goals. Is PEG better option at this point? Help please.


You are asking excellent questions. Trust your instincts. As you know, this is a complex neurologic diagnosis that has enduring adverse effects on all developmental domains, especially feeding/swallowing. One of the mantras I offer all my medical and nursing colleagues and my students, is “co-morbidities matter”. My experience suggests that this is not the perspective that most medical colleges utilize as the framework for their differentials related to ability to feed orally, both for adequate intake and or airway protection. One set of clinical data/findings about dysphagia for an infant nor child will/should lead us to have very different plan of care when the co-morbidities and history are different. There is no pigeon hole or cookbook we can use but rather it requires a complex critical analysis of the data about that patient in the context of his unique history and co-morbidities that must guide our clinical decision-making, It can then become frustrating for those of us who recognize this close relationship between co-morbidities and prognostication, both through research as well as our clinical experience, when options are offered and decisions are made that don’t assure such a differential. While their intentions are clearly good ones, sometimes there is a tendency in these situations for the medical team to want the parents to be happy (i.e., a wait and see attitude), or to not understand the complexity of the underpinnings lacking, or to not appreciate the complex skills required to feed safely and meet nutritional requirements.

I don’t know if there are other co-morbidities, but if so, those will also act as rate limiters for feeding. This diagnosis, and the nature of its pathophysiology, is the lense through which we as SLPs then look at skill progression and, therefore feeding ability and safety. It is highly unlikely his related feeding/swallowing challenges will resolve in the short term (i.e., 4-8 weeks) as their apparent proposed “short term” NGT plan suggests. The NGT may indeed exacerbate EER/GER and create the setting for onset of feeding aversions due to the negative effects of an indwelling tube that makes the oral facial area unpleasant, especially if they decide to do a bridled NGT which may their plan given that at age three, there is also great risk to dislodge the NGT, which in itself creates risk for airway invasion. At 3 years of age, the likely maladaptive motor maps already developed due to likely struggles to feed will create further stress and roadblocks for this child.

I recommend the team strongly consider a PEG forth above reasons. Look at this recent publication that looks at NG instead of a PEG.

Keep up the good work. The child and his parents are lucky to have you in their corner.

I hope this is helpful.


A retrospective review of enteral nutrition support practices at a tertiary pediatric hospital: A comparison of prolonged nasogastric and gastrostomy tube feeding

Ricciuto, Amanda et al.     Clinical Nutrition , Volume 34 , Issue 4 , 652 – 658

They compared prolonged nasogastric and gastrostomy tube use, hypothesizing that earlier gastrostomy improves outcomes. Their results showed: Among 166 patients, the median total tube feeding duration was 24.9 (3.0–75.6) months and varied with underlying disease and swallowing assessment. The median duration of nasogastric tube use was 7.8 (0.7–45.3) months. Food refusal was significantly associated with nasogastric tube exposure >3 months (RR 3.3, p < 0.001, NNT = 3) and anthropometric outcomes were superior in gastrostomy-fed patients. Rates of aspiration pneumonia were similar in both groups. Despite more initial opposition to gastrostomy and a higher complication rate, gastrostomy users appeared more satisfied with their experience, as demonstrated by a much lower discontinuation rate than observed in the nasogastric group. They concluded prolonged nasogastric feeding is associated with increased food refusal and less favorable anthropometric outcomes and earlier gastrostomy placement may be preferable.

Problem-Solving: Struggles transitioning from breast feeding to bottle feeding


I am seeking out any clinical information (research articles, case studies, hospital/center practices or pathways) for treating infants who are struggling to transition from breast feeding to bottle feeding. My center sees many patients, who are often typically-developing and without a significant medical history,  who are excellent breast feeders but are refusing or having difficulty with bottle feeding. Often,  these mothers are under a lot of pressure,  as they are returning to work and worry that their child will be unable to feed while they are apart. Thanks!


In this group of breastfeeding infants who don’t transition to bottle-feeding readily, we may see a wide variety of etiologies even in the subset of otherwise apparently normally developing infants.

I always try to keep my clinical radar open to the less obvious and go from there. Because of the protective controllable flow from the breast (compared to that received from a rubber manmade nipple), the faster (and therefore less controllable) flow rate when offered a bottle may reveal or create true incoordination. Caregivers may select a faster flowing nipple for bottle-feeding without knowing that it often makes bottle feeding harder for  a breastfeeding infant. Perhaps subtle airway differences that may be “manageable” for the infant at breast then make bottle feeding stressful. Perhaps not using the rooting response with the bottle (like mother does at breast) may make organization of the motor maps that underlie the root-to-latch sequence to initiate bottle-feeding difficult. Well-intentioned but ill-advised use of prodding with bottle-feeding  or “spinning the bottle” with bottle-feeding doesn’t happen at the breast; that can override and confuse motor sequencing that creates stop-start patterns and disorganization with the bottle. Caregivers during bottle-feeding may steer the infant back to sucking when he stops to breathe (to accommodate the less manageable flow); this can create physiologic stress when the swallow-breathe interface is then not synchronous.

Taking the infant’s perspective always helps me figure out the “whys” as a starting point. Each infant has his own  “story”, history and parent-infant relationship that makes his clinical presentation unique.  While breastfeeding infants who don’t transition to bottle-feeding readily can be often grouped as a “population”, our thoughtful reflective peeling apart of the layers for each infant is essential. This usually leads me to ask, “what else” (as my friend and mentor Joan Arvedson always says) and keeps my thinking in the “grey zone” where there are more questions than answers and that is a good thing.

I hope this is helpful

Research Corner: Tracheobronchomalacia and CLD in the NICU

Should Neonatologists Rule Out Tracheobronchomalacia in Every Premature Baby With Bronchopulmonary Dysplasia?      Fadous Khalife et al,    J Med Cases. 2019;10(3):72-7   


Commentary from Catherine: This current look at one of the possible adverse effects of prolonged intubation should inform our practice when supporting infants with CLD. Poor coordination and adverse events with PO that may lead to symptomatic or silent airway invasion may have their etiology in TBM. Keep this in your differential as you work with NICU infants who have CLD. Also our kids in PICU who present with persistent airway invasion in the setting of chronic respiratory co-morbidities. A direct laryngoscopy/bronchoscopy by ENT may be something to suggest as you work with your medical team. 


Bronchopulmonary dysplasia (BPD) is a chronic inflammatory lung disease that affects mainly premature infants; it results from the damage to the immature lungs from mechanical ventilation and prolonged use of oxygen. They suffer from obstructive lung disease.

TBM in children is defined as weakening of the airway wall due to softening of the cartilaginous rings, decreased tone of the airway smooth muscle and collapse. This results in increased airway compliance and reduction of the size of the airway lumen during expiration. The clinical manifestations of malacia vary widely: barking cough, impaired mucous clearance, retractions, dyspnea and prolonged expiratory phase. Children can also have atelectasis and recurrent pneumonia leading sometimes to intubation and difficulty weaning from ventilator support. It may be associated with feeding difficulties.

The acquired type is most commonly associated with prolonged mechanical endotracheal intubation (with more significant effect in premature infants), severe tracheobronchitis and external tracheal compression (double aortic arch, innominate artery compression, vascular rings, left atrial enlargement).



Problem-Solving: Feeding Aversions and Noonan’s in NICU


Do you have any suggestions for working with a NICU baby with Moons Rasopathies and food aversion?


Do you mean Noonan’s Rasopathies? You don’t mention much about the infant so lots of pieces that are unclearing terms of problem-solving. Not sure if he is in the NICU currently or was in the NICU in the past. But here are some thoughts.

I always look at the system problems that are contributing, i.e. motor, oral-motor, sensory, oral-sensory then focus on those systems and their breakdown. What are the implications of that diagnosis for the underpinnings for feeding safely and well enough to grow. Aversions in an NICU infant and even in an older child are likely a byproduct of the systems that are altered or impaired.

Typically, with Noonan’s, it is hypotonia and altered craniofacial integrity (structural and muscular), plus the adverse effects of the need for NICU care (? Prematurity? Sick newborn? Need for intubation? Respiratory history? Current need for respiratory support? State regulation? Other complex co-existing co-morbidities – such as cardiac, neuro, GI, airway etc.? )

Be sure reflexes are consistent enough to even try pacifier dips. May look aversive due to infant is trying to protect himself (due to respiratory or swallowing safety issues). Lack of engagement maybe an adaptive behavior, a purposeful attempt to avoid feeding. or it may be lack of skill combined with disengagement. Take time to reflect and sort out “why” infant appears  “averse”. Patience and caution will be critical. Normalizing the oral-sensory system, in the context of the reasons for the apparent  “aversions” (or lack of engagement with feeding) will be a needed part of your problem-solving intervention.   If infant has the prequisites and is engaging, and you decide it appears safe to assess small PO trial, I suggest offering slow flow nipple , sidelying, resting , strict co-regulated pacing and use watchful vigilance. An instrumental assessment early on will be most important to objectify physiology due to high risk for airway invasion related to co-morbidities. Part of your role will likely be to protect the infant from being pushed to PO feed by well-intentioned caregivers.

Hope this helps.


Problem-Solving: Twelve-Month-old with apparent tongue tie and poor chewing


I have a 12-month-old that just came in for an evaluation. Lactation consultant at birth reported tie. Mother reported pain while breastfeeding and inadequate suction. She decided not to have the tie cut. Fast forward to 12 months. They just started to introduce chewables about 1 month ago. I see lingual lateralization with emerging munching–it is inconsistent. He does not drink from a straw. He drinks water and whole milk from a spout. He coughs inconsistently when he drinks and it appears, he is not sipping then swallowing but holding liquid in his mouth—-does anyone have experience with tongue tie impacting the peristalsis movement of the tongue for drinking? Mother reported that during his time drinking from a bottle he did not ever cough.

I got a look at his tongue–it appears to be a posterior tie; however, it is hard for me to tell if this is truly what is impacting him. If peristalsis is impacted could that mean decreased laryngeal elevation? Besides recommendation to a dentist and ENT should I recommend a MBS?

Any input would be greatly appreciated!



Tongue tie is indeed a controversial topic, not only for SLPs but also for our large ENT group, who do not even agree amongst themselves.

I was fortunate as a young pediatric SLP to take an 8-week NDT course (Neuro Developmental Treatment) that was primarily for OTs and Pts and focused on the kinesiology, motor-control and dynamic interrelated components of movement that produce the gross motor, fine motor and oral-motor synergies that underlie functional skills. It also taught us about compensatory motor patterns that can be created by muscular/structural restrictions to movement. It opened a while new world to me about the motor mapping and structural-muscular relationships that are the underpinnings for swallowing and feeding. That perspective has so enhanced my work in dysphagia over many years, and continues to do so, both related to theory, components of movement required, evolution of feeding/swallowing and looking at treatment of feeding/swallowing from a sensory-motor learning perspective.

My clinical experience across the pediatric age groups from neonates through teenagers strongly suggests that truly-tethered oral tissues can change those synergies and create the need for maladaptive/compensatory behaviors with feeding, adversely affecting breastfeeding, bottle-feeding, spoon-feeding, mastication of solids, cup-drinking, and straw drinking.

Amber, I wonder if the 12-month-old you described, who it sounds like was otherwise normally developing, may be having trouble with using the tongue tip and lateral borders of the tongue to move food to the molar ridge and keep it there for chewing and to manage liquid.

Depending on the location of a posterior tongue tie, it may create difficulty accessing the lateral borders of the tongue to assist with bolus control and transport. This can lead to compensations of humping of the back of the tongue or restricted tongue retraction that can adversely affect the swallow. Contraction of the lateral borders of the tongue is required for tongue retraction which is part of the swallow pathway that, yes, as you suggested, could indeed adversely affect pharyngeal peristalsis. There can be pooling of liquid on the surface of the tongue (flattened instead of having a central groove due to restricted “lift of the blade by tethering), creating the need to hold the bolus to avert spilling across the tongue blade into the lateral sulci. If there is a true posterior tongue tie, the muscle coordination with spoon feeding is likely also being affected, though may not be as readily obvious if he can “eat from a spoon.” Compensations during eating can result, including, for example, avoiding/refusing solids, multiple swallows to clear a bolus, ineffective suction with a straw, hard swallows to facilitate bolus transport, overstuffing to ”move food”, swallowing foods not fully masticated, or pocketing due to the inability to transport a bolus properly. Progression to more difficult solids such as meat will be challenging due to lack of disassociation of tongue and jaw movements because a munching pattern is all that is available.

A swallow study, interpreted thoughtfully specific to components of movement along the swallow pathway, can objectify the compensations adversely affecting function. I recently saw an otherwise normally developing 5-year-old referred for a swallow study due to “not chewing”. She had altered articulation (suspicious for tethered oral tissues based on its presentation), refusal of solids, poor cup and straw drinking. Her clinical examination, own history provided through my gentle questions and obvious restrictions in oral motor movements suggested upper lip, anterior tongue and posterior tongue ties. The subsequent instrumental assessment as requested by the MD suggested restrictions in movement that created many of the differences I described above. She was seen by a local pediatric dentist well known of specializing in this area of pediatric practice and had multiple releases. Much relearning was required with her community SLP to support learning of new oral-motor maps and synergies for functional skills. Just one example from many. That does not suggest that all such feeding problems use as examples above are due to ties, but we need to thoughtfully complete a through differential with each infant or child or adolescent, and continue asking questions both during sessions and after, with each other.

My Pediatric PTs colleagues love talking about tethered oral tissues, since they bring such clear understanding of motor synergies and structural-muscular relationships that adversely affect function. Sometimes they say it can affect function quite obviously and at other times, in a more subtle way that alters quality of movement, and affects motor learning going forward, affecting future skills. Might this be applicable to eating and drinking, as it evolves and progresses through motor learning and experience? My thought is yes.

I hope this is helpful.

Problem-Solving: Aspirating 4 month old

Question: “Asking for a fellow therapist. What would you use to measure the effectiveness of vital stim on a 4 mo old who is aspirating severely due to a discoordinated suck – swallow. Other than using a stethoscope to listen to her lungs or if fluid is entering her stomach, I’m not sure how in a home setting we measure effectiveness. She ate a 3 ounce bottle in 15 minutes when I was there so amount of time doesn’t seem appropriate”

My response:

There can be so many etiologies for why an infant has suck-swallow-breathe incoordination. Depending on the infant’s history (was there prematurity? was she a sick newborn?) and medical co-morbidities (neurologic? respiratory? airway? GI?) as well as developmental co-morbidities (postural control? oral-motor? sensory? ),  the interventions selected will be different and specific to that etiology.

Sometimes it can seem helpful to just “find a tool”, like a NUK brush or a popular bottle or a marketed option, and then use it to “make the feeding better.” But that doesn’t work.

Don’t try to find an answer, ask more questions. Take the time to” look at” and listen to and “feel” the baby when she is feeding so you can figure out why she is “not coordinating”

Slow flow nipples, co-regulated pacing, resting, changes in positioning and guided participation with caregivers can  enhance both intake and quality of feeding, when provided by a  SLP with expertise in infant feeding/swallowing. But only after knowing why you would be using them.
Maybe Vital Stim is not an appropriate intervention, given her history, clinical presentation and your assessment. You need to find out and to ask the questions.

If feeding is new to you, seek out a colleague to work alongside you that you can learn along with. The infants we see today are quite complex for all of us.

It is quite rare  that a tool is the answer — a tool is only useful when preceded by critical thinking about why. Too often, grabbing, for the “tool” is like grabbing for a cookbook —  and its stifles your thinking. Remember cookbooks were made for cooking not for feeding.

Step back, take a deep breath and  look at the baby through new eyes. I bet you will start to answer some of the questions I posed and you will have more questions of your own about what your observations and her behaviors might mean. Then you think some more, ask more questions. Seek out a colleague’s eyes to look along with you. Then think some more with that colleague .

I know you were hoping to have someone just provide a protocol, but I am hoping instead you will let yourself think and live in the “grey zone” as I like to call it  (where answers are not quick and one must be ok with not being sure, not have answers, need to ask more questions, ask “what else” do I need to consider), because that is how one becomes a more skilled clinician.

Also need to think about: why she is aspirating? What is the etiology?

There are multiple possible reasons along the swallow pathway that can lead to maladaptations and bolus mis-direction in the context of her unique history and clinical presentation.

When was the instrumental assessment done? was the infant at her best then? has she changed since then in ways that might affect swallowing/feeding function? is there need or PT and/or OT  or other medical specialists to help sort out the “why”? is she otherwise normally developing?…. I ask all this because, as you know, we don’t treat the problem, we treat the infant.

Without understanding why she aspirated we are likely going to “throw a bunch of  interventions at the problem” and they may be inappropriate, ineffective or ill-advised, given what is really going on and the bigger picture.

I hope this is helpful.


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

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

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

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

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

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

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

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




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

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

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

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


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

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

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

Commentary from  Catherine:  

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

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

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


Research Corner: Pediatric Feeding Disorder Consensus Statement

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

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

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

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


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

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


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

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

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

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

I hope this is helpful.

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


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

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

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


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

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

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

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

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

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

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

I hope this is helpful

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.