Catherine Shaker Seminars: Wrapping Up 2023 in Boston

During 2023, I traveled from the heartland to the East coast, and met some amazing people along the way. From past colleagues who joined me in Miami, to the dedicated team at Riley Children’s Hospital, to the NICU nurses who learned along with STs/ OTs/PTs at my Cue based Feeding seminar, to the staff and children at Elizabeth Seton Children’s, and the dynamic team at Boston Childrens. From all coasts, therapists joined us to share our common passion for neonatal/pediatric feeding and swallowing. So many remarked about the gift of being in the same room, networking and enjoying higher-level conversations with each other and the group. From deep dives across multiple components of assessment and intervention, to practical solutions and case problem-solving, to considering the impact of the current research on our practice and navigating the practice challenges each of us faces on a daily basis. We each left feeling renewed.

I am finalizing next year’s schedule, which will take me across the US. Sign up for my blog on my website to receive a notification when my 2024 Seminar schedule is posted.

I continue to be grateful for each of you who shares my passion for neonatal/pediatric swallowing and feeding. I hope our paths cross in 2024!

Catherine

 

Some of my favorite comments over the year:

“I have been waiting for an advanced course where we could all interact and learn from each other. I finally found it. I might even come again next year and participate with a different group. Such great problem-solving about so many different types of pediatric patients. Thank you! Veronica, SLP

 “Thanks for being such a spark to help me keep learning! I learned more in two hours than I did in four days at a different conference. Thanks too for your willingness to both objectively discuss and answer questions about things with which you both agree with and disagree.” Emma, SLP

 “I came away with so many strategies and a better understanding of what to look for when working with a child. Really helped me look at the whole picture”. Priscilla, OTR

 “Your course is a huge bang for my buck! Honestly invaluable. Your real-life experiences helped apply the research and knowledge you shared. And for referencing so many other excellent professionals working in the field. Really filled in the blanks for me”. Kerry, SLP

“Even for someone like me who doesn’t do VFSS, I learned so much about the biomechanics of the pediatric swallow that now can inform my treatment”. Leana, SLP

 

 

 

Problem-Solving with Catherine: Considerations with Positioning in the NICU

Question:

What age would you typically start trialing an NICU babe in a more upright seat (e.g., Tumble forms feeder seat)? Thanks!

Catherine’s Answer:

Elevated sidelying as you know has an increasing evidence base that consistently supports its benefits for our NICU infants during PO feeding and also for developmental support. Semi-upright can be supportive for motor learning during non-feeding experiences (and post-discharge as a feeding intervention) when the infant’s postural mechanism and motor learning are ready for that experience.

I don’t think of a particular age or weight as criterion. That would make the basis for this critical intervention too arbitrary, since we recognize that typically infant A and infant B can, while the same weight or size, have very different clinical feeding presentations, and different readiness for tolerance of semi-upright (specific to head/ neck/postural control, WOB, tidal volume and reserves, GI comfort, and swallow-breathe interface).

Whether for motor-learning and/or feeding, I always “ask the infant” by carefully considering that infant’s unique readiness – or lack thereof – specific to these factors, in the setting of their unique history and co-morbidities and developmental goals. That way the intervention – in this case, progression to supported semi -upright – is more likely a true match for our therapeutic goals. And best meets the risk-benefit ratio that underpins our clinical reasoning.

The more I understand about the postural mechanism, sensory motor learning, the effects of gravity on multiple systems, and the potential to recruit adaptive behaviors (and provoke maladaptive behaviors) – the more I’ve learned that positioning is too complex of an intervention to be based on arbitrary points in time.

Join Catherine Shaker in Boston: Deep Dives and Practice-Changing Essentials

 

Intellectual curiosity is known as one of the hallmarks of a lifelong learner. The intellectually curious person has a deep and persistent desire to know and seeks answers to those essential “why” questions that underpin our “differential” in swallowing and feeding.  Then you peel back the layers to take a deep dive, think critically, then map key interventions. And that changes everything…..for your pediatric patients …and for you!

Are you a lifelong learner? Then an exceptional learning experience is waiting for you in October in Boston at Boston Medical Center. A welcoming environment that fosters interaction and learning along with each other.

  • Pediatric Swallowing and Feeding: The Essentials:  Oct 13-14
  • Pediatric Video Swallow Studies: Physiology to Analysis:  Oct 15
  • Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Issues:  Oct 16-17

What your colleagues are saying:

“So informative but also fun. A deep dive into a blend of the art and science of what we do, and how to use objective data to be critical thinkers.” Megan, SLP

“Thanks for being such a spark to help me keep learning! I learned more in two hours than I did in four days at a different conference. Amazing to have 20+ pages of current references that were woven into our discussions. Michaela, SLP

“I came away with so many strategies and a better understanding of what to look for when working with a child. Really helped me look at the whole picture”. Priscilla, OTR

“Your course is a huge bang for my buck! Honestly invaluable. Your real-life experiences helped apply the research and knowledge you shared. Thanks for referencing so many other excellent professionals working in the field. Really filled in the blanks for me.” Kerry, SLP

“Even for someone like me who doesn’t do VFSS, I learned so much about the biomechanics of the pediatric swallow that now can inform my treatment. Leaving with excitement and energy to apply this knowledge!” Leana, SLP

Catherine’s experiences and knowledge base are priceless. Being able to hear her perspective on certain topics and/or ideas is a breath of fresh air. Organized, easy to understand, and offered multiple balanced perspectives” Hannah, SLP

Catherine Shaker Seminars: Exceptional Opportunities in Yonkers and Boston Around the Corner!

Join me for advanced clinical learning opportunities in Yonkers NY (September) or Boston (October)! Each state-of-the-art seminar is infused with the latest research, problem-solving, deep dives for critical thinking, and strategies you can use the next day. A welcoming environment that fosters interaction and learning along with each other.

  • Pediatric Swallowing and Feeding: The Essentials: Yonkers NY Sept 20-21, Boston Oct 13-14
  • Pediatric Video Swallow Studies: Physiology to Analysis Yonkers NY Sept 22, Boston Oct 15
  • Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Issues   Yonkers NY Sept 23-24, Boston Oct 16-17

What your colleagues are saying:

Thanks for focusing on the why’s and how’s and promoting problem-solving and critical thinking when it comes to our kids. Tammy, OTR

So many things I appreciated in the Advanced course! Picture examples, the variety of diagnoses covered, planned times for questions, case discussions, anecdotal stories to help with understanding, and so much foundational research for each topic. Maggie, SLP  

Your Swallow Studies course was the most detailed education I have had related to the dynamic interaction of the oral, pharyngeal and esophageal phases and how they play on one another. Your breadth of well-rounded knowledge and ability to easily relate it to practice is wonderful. She is so approachable which makes it a comfortable environment. The research you provided is phenomenal. Lisa, OTR

Gained a deeper knowledge of factors that I haven’t given enough thought to in treatment and am more aware of current tools/trends in feeding/swallowing. I love that you and Theresa spent so much time on intervention. Eva, SLP

Problem-Solving with Catherine: Proactive versus Reactive NICU Consults

NICU Nurse Decal by AdriansVinyl on Etsy

Question Our institution is currently in the midst of updating the process for order consults in our NICU. We are moving forward with a more proactive approach and proposing automatic/standing orders for all three rehabilitative disciplines (SLP, OT, PT), but at differing times. While there is a lot in the literature suggesting a more “proactive” vs “reactive” approach is optimal for this population, some staff have asked about what specific organizations across the US are doing utilizing this approach, and what the findings have been. I have found it challenging to find specific information within the research to respond to these questions, so thought this would be a great place to get some additional information. I have a few questions and would greatly appreciate any feedback or additional information that you would be willing to share! This will greatly help as we look to expand our program and improve feeding outcomes for our neonatal patients.

Does your institution have automatic orders/standing orders? If so, what level is your NICU?  Also, are orders placed at time of admission for SLP, or is it based on specific gestational age or any other specific parameters?

 

Catherine’s Answer: Having a solid working relationship with your NICU team seems to be the key. I think that underpins their willingness to develop policies that reflect the value they believe that you —and SLPs–add to the developmentally supportive care they are committed to.

As I travel across the US teaching about NICU practice related to feeding, I often ask this question of SLPs in both Level III and Level IV NICUs. My informal data set suggests that about 50% of the SLPs report being in an NICU with standing orders, they most often occur at 31-32 weeks PMA. I suspect that is because there is literature correlating younger GA with increased risk for feeding problems. About 10 % of the SLPs, sadly, have stated there is no criteria and that it is “hit or miss” or consult is received at the “eleventh hour” or when the infant has had persistently poor feeding, now has aversions or only if the infant has “death defying events.”

The others don’t have standing orders. Approximately 40% have co-morbidity-based criteria, similar to Amber’s. The co-morbidity-based approach has increasing evidence-base in the literature, including for example, younger GA at birth, protracted need for ventilation, CHD, CLD, NEC, need for PDA, HIE, NAS.NOW, laryngomalacia, EA/TEF, reflux. For those neonatologists who truly value an evidence-based approach, the co-morbidity-based criteria often just makes sense, and they readily embrace it. They are often the colleagues for whom their clinical wisdom matters, i.e., they are quite in tune about those medical diagnoses for infants whose LOS is often prolonged related to poor PO feeding and seek SLP input to support improved feeding outcomes.

We have come so far in our data about the most fragile infants in the NICU cohort, known to be at heightened risk for enduring feeding problems. That, combined with the AAP’s recent guidelines, has opened new doors. The new neonatal care standards from the American Academy of Pediatrics recognizes the expertise of SLPs for supporting feeding, swallowing and neurodevelopment, as part of an interdisciplinary NICU team alongside OT and PT. Minimum standards for Level II, III, and IV are specified, with a goal to “improve neonatal outcomes by ensuring that every infant receives care in a facility with the personnel and resources appropriate for the newborn’s needs and condition.”

Both Level III and Level IV NICU Requirements support consistent presence of SLPs in the NICU and ensure that NICU patients and their families receive the services they need to thrive in the NICU and after discharge. This includes onsite access to an SLP with neonatal expertise, who is skilled in the evaluation and management of neonatal feeding and swallowing concerns.

Going forward, we hope that cross-fertilization of knowledge continues amongst all NICU team members, so that our expertise as SLPs for fragile infants learning to PO feed in the NICU continues to gain recognition.

I hope this is helpful. Keep up the good work on behalf of our tiny humans.

 

Catherine Shaker’s Pediatric Swallowing and Feeding Seminar: Feed Your Mind!

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If you are looking for an exceptional educational opportunity designed with you in mind, this is it. Join your colleagues for Pediatric Swallowing and Feeding: The Essentials to take your pediatric feeding/swallowing practice to the next level!

  •  Sept 20-21 in Yonkers, NY (Elizabeth Seton Children’s Center)
  •  Oct 13-14 in Boston MA (Boston Medical Center)

I bring my passion for feeding and swallowing to every course I teach, and designed my Pediatric Swallowing and Feeding: The Essentials course to integrate foundational and advanced essentials —–  typical development (our template for therapy), atypical development, oral-motor, sensory, sensory-motor, development of the swallow from birth on, tools of the trade, tubes, trachs, preemies, TOTs, airway, swallow studies, weaning tubes, a wide variety of interventions and the “whys” behind them — to support challenging practice needs. I weave in the research and multiple levels of learning to build critical thinking that you can apply to your complex patients immediately.

What Your Colleagues Are Saying:

Thanks for being such a spark to help me keep learning! I learned more in two hours than I did in four days at a different conference. Thanks too for your willingness to both discuss and answer questions about things you both agree with and disagree with. Emma, SLP

I came away with so many strategies and a better understanding of what to look for when working with a child. Really helped me look at the whole picture. Priscilla, OTR

The breadth of material/subtopics covered was amazing. My families and co-workers now have a more competent clinician working with and advocating for them. The course was highly informational, even after my 20+ years as a pediatric SLP. Colleen, SLP

I take a lot of CE courses and I would rate this as one of the best. Catherine and Theresa’s knowledge base and how they presented the material has increased my confidence and skill! Laura, SLP

 

Problem-Solving with Catherine: Critical Thinking in the NICU and Beyond

Sunday Thoughts: Race and IQ Yet Again? | Right Wire Report

QUESTION:

I am an adult acute care SLP. My hospital has an accredited NICU that is fairly busy. We have NICU trained PT’s that work w/ the babies but currently no SLP. An SLP who no longer works in our hospital used to service this population. I am wondering what type of credentials an SLP is required to have to service this population (NICU)? Any specific course and training required? I am inquiring about this for future candidates when interviewing. What training is an absolute “must-have” before an SLP can work with these critical babies? Thank you for any information you can share. From reading this SIG, I know many of you have this area of expertise.

CATHERINE’S ANSWER:

Working as a speech-language pathologist in the neonatal intensive care unit (NICU) requires many specific skills and advanced learning. These tiny patients and their families are fragile. The family-centered care we provide as SLPs, in support of neuroprotection, communication and safe feeding, create the foundation for a thriving parent-infant relationship. The NICU infant’s history and co-morbidities are often complex and require high-level problem-solving to keep them safe and to sort out all the pieces. It is a privilege to be a part of the NICU team, and it comes with much responsibility. The following are some of the elements of professional skill, expertise and that stand out to me as key for practicing in the NICU.

There are to my knowledge no agreed upon credentials for working with this fragile population, unfortunately. ASHA does have guidelines that you can take a look at. It reflects your thoughtfulness that you reached out to plan ahead for future interviews and hiring. I often receive e-mails asking for insights from adult SLPs working in a medical center, who have been “selected” to staff a new NICU. There are of course no black and white answers to your questions. And we all have to start somewhere. And no one knows everything. It would be no different if tomorrow I were asked to work in adult ICU at the very large medical center in which I have work as a senior neonatal/pediatric swallowing specialist. I could technically treat adults in ICU because it is in our scope of practice as SLPs, but it would be ill-advised, unfair to the patient and family and likely place me in a potentially litigious situation should something adverse happen based on my recommendations or lack of insight and would be clearly noted by an attorney or an expert witness. The risks all around would not be a good situation. But often inpatient pediatric specialists are asked to “cover” adult care when peds volumes are “down”. Each of us has a different perspective on risk and what is an acceptable risk for our patients and for ourselves.  Practice in the NICU is a subspecialty of pediatrics, and is to me the riskiest of all, as these are our most fragile patients.

Infants in the NICU are critically ill or were in the recent past. These most fragile patients can become physiologically unstable at any time-and it might happen during our therapy session. It’s not easy to practice in the NICU environment. Quick and constant losses and triumphs cause emotions to run high. An infant’s status can change at any time. Caregivers are highly skilled and passionate, which sometimes leads to strong opinions and respectful disagreements. The SLP needs to thoughtfully collaborate, yet at times take a stand. Another key trait: humility, and a passionate willingness to learn along with other disciplines. No one knows everything, or if they get to the point that they think they do, it is time to step away and retire. The NICU is too demanding in my opinion to be an initial independent placement after graduate school.

The NICU SLP requires advanced practice skills: It’s not just knowing what to do, but what not to do.  A large focus of our work is supporting feeding/swallowing, so the risk of compromising an infant’s airway is significant. Another essential skill: solid critical reflective thinking. As Drs. Evangelista, Blumenfeld and Coyle told us, “In our work as dysphagia practitioners, we’ve found that a combination of clinical experience and deliberate, effortful reflection on our own practice picks up where graduate school left off. This combination continues to serve an invaluable developmental purpose as we hone our clinical expertise in dysphagia.”

Another key element is solid mentored experience with progressively complex birth-to-3 patients, optimally in a setting which provides an interdisciplinary team approach with PT-OT-ST that supports families and each other as professionals, for a wide variety of infants ranging from very mild to complex feeding and swallowing problems and co-morbidities. It is so hard to access that kind of guided learning when an SLP has to be on the road so to speak and practice in a silo. It is hard to even conceptualize what you don’t know, and to not have someone to bounce questions off of in the moment or really “look” at an infant when you have only your own set of eyes, yet those eyes are still “learning”.

The right foundational pediatric environment will provide critical experience communicating with and supporting parents who are in various stages of grief. These stages of grief are experienced by families in EI even when the infant has never been in an NICU. It provides an opportunity for us as compassionate SLPs to listen, understand and learn how to support in ways that offer guarded optimism, and talk about difficult considerations that underpin airway protection. So that then, later in the NICU, when we work with families who nearly lost their infant, have an infant who is getting worse, or who is unsafe when PO feeding, we have some understanding of the thoughtful communication that is required. The communication from the infant, the child, and the family must always be the lens through which we problem-solve and intervene.

Another key element is the ability to complete a differential, and utilize broad, multi-system knowledge about preterm development and swallowing/feeding and complex medical co-morbidities that are common in the setting of an arduous medical course. This learning comes from multiple sources—previous birth-to-three mentored experience, previous complex patients prior to the NICU, on-going reading of the literature (not just within our field but also in medical, nursing and OT/PT journals) And then the NICU SLP must be ready and willing to not only understand the evidence base, but to bring it to the NICU team. Neonatologists and neonatal nurses will often ask “why?” and we must be able to discuss the research-based evidence along with our clinical wisdom. Ideally guided participation can be provided by learning along with a skilled NICU SLP to further support the critical thinking that is part of this “element” to look for during an interview.

Continuing education is essential because much of our learning about the NICU population comes after graduate school.  That means the hiring hospital must be dedicated to providing the support for education that will best avert sentinel events and optimize the risk-benefit ratio for the institution, the SLP, families, and most importantly, the infant. The courses should be functional, bring the current pertinent research, promote critical thinking not just information, and offer a deep dive across multiple components of assessment, intervention, and co-morbidities – because NICU SLPs will likely see many of them – often in a complex combination that will take patient problem-solving to peel apart. Underpinnings for (and aberrations of) feeding and swallowing in preterm and sick newborns are essential—WOB, state regulation, airway, postural control, sensory, GI, and neurodevelopment, and also the breadth of infant-guided interventions and their rationale in the NICU—-as they will all need to be a part of a differential and plan for safe swallowing. Also, the interaction of the evolution of swallowing physiology (unique to the impact of preterm delivery and/or critical illness for the term infant), airway protection and considerations for instrumental assessment (why, when, how, analysis and collaboration with the team). When I first started in the NICU in 1985, I was fortunate to come to this unique setting after 12 years of solid Birth-to-Three experience with complex infants and children, with wonderful mentors who helped hone my skills over many years.  Despite that, there were so many gaps, and starting in the NICU back then still required me to embrace being a lifelong learner and building a dynamic foundation. Even after many years of complex infant feeding and swallowing experiences (across outpatient, EI, acute care and NICU settings), I still have to pause and really think through these complex little ones, because every experience matters in the NICU. My continuing education offerings, especially my new Advanced Infant/Pediatric Dysphagia seminar are all infused with critical thinking. As Drs. Evangelista, Blumenfeld and Coyle told us, “In our work as dysphagia practitioners, we’ve found that a combination of clinical experience and deliberate, effortful reflection on our own practice picks up where graduate school left off. This combination continues to serve an invaluable developmental purpose as we hone our clinical expertise in dysphagia.” See: Evangelista, L., Blumenfeld, L., & Coyle, J. (2022). How Do We Cultivate Critical Thinking in Dysphagia Decision-Making? ASHA Leader Live.

I hope this is helpful. This relationship-based nature of our work in the NICU, and its potential to influence lives in so many ways, must remain as much a part of our day-to-day interactions with families, always inextricably linked to our critical thinking and problem-solving. As you can see, I am passionate about our work in the NICU, and the tiny humans we care for deserve no less.

 

Problem-Solving with Catherine: PO Feeding and “Chronic on Acute” Viral Processes

QUESTION: Anticipating the coming likely increase in RSV, we are expecting to be treating a lot of babies that are weaning from heated high flow nasal cannula on our pediatric unit. We are typically not feeding babies until they wean to 2L. Do you feed before that?

CATHERINE’S ANSWER: Such great commentary on a challenging clinical issue. For each infant, we need to develop a unique algorithm based on multiple factors. With our infants who were previously normally developing and are hospitalized for a viral process (such as RSV) or respiratory illness (such as bronchiolitis), we would anticipate their feeding challenges will be temporary, and will follow the trajectory for recovery of an acute, not chronic, process. Infant-guided interventions such as manageable flow rate, co-regulated pacing, resting, and supportive positioning that optimizes respiratory stability will be helpful, along with honoring the infant’s disengagement form feeding.

Contrast that with those infants with pre-morbid relevant diagnoses and or co-morbidities that may suggest “acute on (top of) chronic” problems. With this group, we would consider then the impact of their feeding history prior to admission (PTA), their co-morbidities PTA (very complex? moderately complex? one system only?), and aspiration risk (extremely fragile – high Fi02 versus stable with significant support- moderate Fi02 versus weaning support regularly – Fi02 21%), trajectory of their course (weaning of support versus interval escalation), and the prerequisites detailed so well by Hema, above. All of this is considered in the setting of risk to their health/recovery if that infant aspirates or micro aspirates. We might begin that continuum of return to PO feeding via pacifier dips for purposeful swallows as WOB and respiratory stability permit, working closely with RT, followed by the infant-guided guided interventions as described above, watching for subtle stress cues, infant communication and physiologic stability from moment to moment. All of this proceeds with careful attention to the on-going resolution of the viral process(es).

I hope this adds to your critical thinking. Pausing to reflect, as you did, really is the key to mitigating risk for these fragile infants.

Shaker Indy Seminars: Learning along with new and familiar colleagues

Sri

Michelle

Emily

 

 

 

 

 

 

My recent visit to Indy was special in so many ways.

The Feeding and Swallowing Team at Riley Children’s Hospital in Indy were wonderful hosts!  Speech-Language Pathologists and Occupational Therapists joined us from across the US and Canada to learn interactively along with each other, focusing on a wide variety of practice settings.

I was also blessed to re-connect in person with Michelle, SLP extraordinaire who is also a pediatric Passy-Muir consultant who first came to my courses 20 years ago! And there was Emily, NICU SLP who now services my first NICU, that “built me from the ground up” almost 40 years ago in Milwaukee.  And we were joined by Sri, an Assistant Professor from Michigan who teaches our graduate SLPs and came to learn more about neonatal and pediatric swallowing and feeding. Their intellectual curiosity, after years of experience, inspires each of us to be lifelong learners. Really reminds me of how grateful I am to be part of such an amazing group of professionals supporting our infants, children and families. And what a gift it is to learn along with them …… and with you.

 

 

 

AAP 2023 Neonatal Care Standards: Recognizing the Value of Rehab

NICU Nurse Decal by AdriansVinyl on Etsy

The American Academy of Pediatrics has just issued new neonatal care standards that now recognize the expertise of SLPs for supporting feeding, swallowing and neurodevelopment, as part of an interdisciplinary NICU team alongside OT and PT. Minimum standards for Level II, III, and IV are specified, with a goal to “improve neonatal outcomes by ensuring that every infant receives care in a facility with the personnel and resources appropriate for the newborn’s needs and condition.”

Both Level III and Level IV NICU Requirements support consistent presence of SLPs in the NICU and ensure that NICU patients and their families receive the services they need to thrive in the NICU and after discharge. This includes onsite access to an SLP with neonatal expertise, preferably certified in neonatal therapy, who is skilled in the evaluation and management of neonatal feeding and swallowing concerns.

How the NICU rehab “workload” is shared depends on each NICU team’s interprofessional practice, and the unique expertise of rehab team members. That working relationship, no matter what way it is designed in each particular NICU, is the key to meeting the needs of the infants, their families and staff. Together, the rehab team addresses six core practice domains (environment, family and psychosocial support, sensory system, neurobehavioral system, neuromotor and musculoskeletal systems, and oral feeding and swallowing) in order to provide appropriate care for the neonatal population.

Stark, A. R., Pursley, D. M., Papile, L. A., Eichenwald, E. C., Hankins, C. T., Buck, R. K., … & Faster, N. E. (2023). Standards for Levels of Neonatal Care: II, III, and IV. Pediatrics151(6), e2023061957. See attached via open access on Google Scholar

 

 

Problem-Solving with Catherine: Essentials for Pediatric Dysphagia Practice

How to Develop Whole Brain Thinking?

Question: 

I did infant feeding many, many years ago. Just got referrals for a 4-month-old, NG tube, congenital heart disease, some bottle feeding, and a 3-year-old with a trach. What CE courses would get me up to date ASAP? Most of my feeding work in the past 10 years has been food avoidance and oral motor/chewing related difficulties in toddlers.

Catherine’s Answer:

The key is finding the course that best aligns with your current needs, is functional, brings the current pertinent research, promotes critical thinking not just information, and offers you a deep dive across multiple components of assessment, intervention, and co-morbidities—because you will likely see many of them across your career— often in a complex combination that will take patient problem-solving to peel apart. The outpatient population you follow often will be NICU graduates or toddlers and beyond in the midst of being “sorted out” with families who need both information and support. The key is to commit to being a lifelong learner. No one knows everything, or if they get to the point that they think they do, it is time to step away and retire. Expect that there will be clinical missteps along the way. We all have them. As Drs. Evangelista, Blumenfeld and Coyle told us, “In our work as dysphagia practitioners, we’ve found that a combination of clinical experience and deliberate, effortful reflection on our own practice picks up where graduate school left off. This combination continues to serve an invaluable developmental purpose as we hone our clinical expertise in dysphagia.” This perspective is perhaps more essential to your journey than the invaluable information you will learn along the way. Always remember that.

I bring my passion for feeding and swallowing to every course I teach, and I remember what it was like 45 years ago to start out but not know where to start. I designed my Pediatric Swallowing and Feeding: The Essentials course to provide what I really needed back then — a foundation in typical development through the age of 5 (our template for therapy), atypical development, oral-motor, sensory, sensory-motor, development of the swallow from birth on, tools of the trade, tubes, trachs, preemies, TOTs, airway, swallow studies, weaning tubes, a wide variety of interventions and the “why” behind them. I weave in the research to help you, resources to take away and integrate multiple levels of learning to build critical thinking. I’ll be in Indy (July 19-20), Yonkers NY (Sept 20-21) and Boston (Oct 13-14).

Our discussions will include critical thinking across all ages and co-morbidities, because it’s not just learning “what to do” but what “not to do” clinically. And the weaving in of compassionate family-centered care, which must go hand in hand with the clinical expertise we bring. So that every feeding experience matters. It is, as one of physician mentors told me years ago, all about finding the balance between the art and science of what we do. The communication from the infant, the child, and the family must always be the lens through which we problem-solve and intervene. Each of us has had a moment when we really “listened”, and it changed our practice forever. Mine was in 1985, with a wonderful mother of a critically ill preterm infant, and it has stayed in my heart. This relationship-based nature of our work, and its potential to influence lives in so many ways, must remain as much a part of our day-to-day interactions with families, always inextricably linked to our critical thinking and problem-solving.

See: Evangelista, L., Blumenfeld, L., & Coyle, J. (2022). How Do We Cultivate Critical Thinking in Dysphagia Decision-Making? Leader Live.

Shaker Seminars: Learning and Renewal …. Miami Style …

Tropical Beach at Sunset with Palm Trees Graphic by Astira · Creative  Fabrica

The Feeding and Swallowing Team at Baptist Health in Miami, Florida were amazing hosts! And what a backdrop for learning and a relaxing renewal of our spirits. Speech-Language Pathologists and Occupational Therapists joined us from across the US to learn interactively along with each other, focusing on a wide variety of practice settings, problem-solving our neonatal through school aged patients.  In the NICU Swallowing and Feeding Seminar we enjoyed higher level conversations about complex feeding challenges in the NICU and after discharge, considering impact of co-morbidities, and problem-solving next steps. We were blessed to have a pediatrician join us! She thoughtfully offered her insights that informed everyone’s practice and supported our navigating those sometimes-difficult discussions with the team. In the Pediatric Swallow Studies seminar, we considered the unique components of the swallow pathway across the pediatric age span, through videos and stills, and then how to peel apart the pathophysiology and its implications for both function and for treatment.  Both seminars gave us opportunities for conversations, in the group discussions and informally at breaks, to share the same struggles, and our solutions. It was exciting to discuss the impact of the latest research and meld that with our collective clinical wisdom. We all walked away feeling renewed, remembering that we are all in this together, and we are all always learning.

I am looking forward to learning along with many of you in Indy in July!

Problem-Solving with Catherine: Former Late Preterm with Stridor

What Is Colic? Causes, Remedies and Symptoms of Colic in Babies

Question:

Problem solving question with a kiddo with reflux. Previous 35w5d baby spent 24 hours in the NICU for low blood sugars and high bilirubin and low body temp. He needed to be on a warmer for 2 hours. He did not need lights or other intervention other than feeding for blood sugars and bilirubin.

Feeding difficulties from the beginning but progressively worsening reflux that correlated with stridor. His last MBSS showed better coordination with thins and less prespill to valleculae and pyriforms on Avent anti colic with level 2 nipple compared to slightly thick on level 3. Increasing prespill to valleculae and pyriforms with 2 episodes of penetration above the cords with slightly thick. Recommendation for reflux is usually thickening feeds but his OP swallow wasn’t as coordinated on thickened feeds. How can we manage reflux and not have poor OP swallow function? He has an appointment with an aerodigestive clinic but was hoping to implement something sooner as he is very uncomfortable and colicky.

 

Catherine’s Answer:

Sounds like he was a late preterm. I have lots of questions to help me understand what the relevant factors might be.

What is the PMA (adjusted age) now? When was he discharged from the NICU? How long has he been with you in OP? Are there any other diagnoses/co-morbidities we know about so far?

How is weight gain and stooling?

When is the aerodigestive workup?

Was reflux a presumptive diagnosis or based on objective data? Is he being treated pharmacologically or non-pharmacologically for reflux?

Was there stridor only at rest? Or also with PO?

How do we know the stridor is provoked by reflux? It could be, in an attempt to close the airway to “stop” the refluxate from entering, or it could be an inspiratory stridor associated with co-occurring airway invasion, or it could be due to problems with structural integrity of the larynx, or a combination of each of these.

Did he have a scope by ENT at the bedside to determine etiology for stridor? Without that, we are guessing about the “why”. It could provide excellent data re whether EER/LPR is the reason for stridor and/or airway lack of integrity. Reflux could also be adversely affecting laryngeal sensation and further compromising swallowing safety. But we cannot guess at that and then formulate a plan for optimizing safe feeding.

Was the study during NICU stay or after discharge? Your calling it an “OP swallow” suggest it was after d/c from NICU..? What was the feeding plan at discharge home? i.e., no PO, PO with NGT backup or? When was that swallow study (i.e., how long ago?)

During the VFSS: Was there pacing offered? Avent nipples tend to run fast and could be increasing aerophagia (exacerbating reflux)..? It would likely be too fast a flow with thin to use a level 2 – that increased flow rate may have predisposed such a young infant to mis-direct the bolus. Did they then try a slower flow rate such as a Dr. Brown’s preemie or ultra preemie – we often use those with preterms to optimize swallowing safety. Thickening only as last resort after those nipple options trialed if indicated.

Normal NB infant swallowing physiology is to actively drive the bolus into valleculae,  but the premature entry to the pyriforms is not a normal variant and suggests a delay in swallow initiation – the question is why – and could be figured out by seeing the swallow study. Could be there was reflux in or coming up the esophageal body and neural messaging “told the infant” to “pause the bolus” and maladaptation occurred (laryngeal penetration). Could be there was increased WOB, typical of  late preterm, and that caused swallow-breathe incoordination that lead to LP. Could be that there are airway problems causing the stridor (especially if it is heard at non-feeding times) that alters timing of the swallow -breathe interface.

What was used to thicken? Rice? Oats? The increase in loss of bolus control is likely related to the higher flow rate nipple, one would think or if the thickener was not binding or mixed well..? or was EBM? Were the LPs shallow/midway to the vocal cords or deep to the level of the cords? In either case, the LPs are worrisome given the bigger picture, but especially if they were to the level of the true vocal cords (deep).

That suggest that there is a very high risk of events of silent and/or symptomatic aspiration during the course of a true feeding based on research findings and my experience as well.

Does the infant have a means of alternate or augmentative nutrition, or all PO? PO feeding without the aerodigestive data seems risky, both based on “precarious”/limited data from the VFSS, limited information about impact of interventions and etiology for swallowing pathophysiology, unclear etiology(ies) for the stridor and potential for airway invasion. His apparent discomfort and colicky behavior could be response to airway invasion, and not reflux.

Look forward to further information to help us problem-solve.

 

Catherine Shaker Seminars: Elevate Your Infant Feeding Practice

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Join Catherine Shaker to take your infant feeding practice to the next level. Whether you are in the NICU or in Early Intervention, key information you can use right away with infants on your caseload. Indy in July and Baltimore in August

  • NICU Swallowing and Feeding: In the Nursery and Early Intervention July 22-23
  • Neonatal/Pediatric Video Swallow Studies July 21
  • The Early Feeding Skills Assessment Tool: A Guide to Cue-based Feeding in the NICU: August 29-30

In the NICU Seminar and Early Intervention, critical thinking and problem-solving based on real life infant clinical experience over 45 years. Latest research. Assessing and treating complex sick newborns and preterms with swallowing feeding challenges, trachs, tubes in the NICU. Foundations for supporting the complex infants discharged to you in EI from the NICU. In the Video Swallow Studies Seminar, focus on the entire swallow pathway and its potential for compensations and maladaptations in relation to co-morbidities, from birth on. Looking at the evidence-base, the big picture, and use of critical reflective thinking, not a cookbook approach; even if you don’t “do swallow studies” increase your understanding and be more skilled at referrals. In the Cue Based seminar, Dr Suzanne Thoyre and I do a deep dive into infant-guided cue-based feeding, the evidence-base, complex feeding challenges in the NICU and after discharge in EI. Analyze and score videos of infants feeding and problem-solve next steps.

 

 

Problem-Solving with Catherine: 15-month-old with TOTs and Difficulty Chewing

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Question:

What am I missing? 15m old, chewing crunchy things, meats and starches (muffins, toast, fruit breads) and swallowing without difficulty. Drinking juice (not water) from a straw. Eating dried fruits and snap pea crisps well. But fresh fruits and veggies, we are making almost no progress. Will put most trials in his mouth, chew then push out, then refuse further attempts. Likes yogurt but refuses all other purees. No trouble with getting hands messy. GI had no concerns, did an MBS with no notable findings. Frenectomy recommended by ped dentist to be done soon.

Catherine’s Answer:

Is he otherwise normally developing without any feeding history that sounds worrisome? What is his overall sensory system like? Any history of reflux? I wonder about the swallow study results and data that was obtained. While there apparently was no witnessed aspiration, did they describe swallowing physiology in the findings? That data can provide more information about muscular synergies and the multiple components that underpin chewing that might be problematic. It is not uncommon for swallowing physiology to be altered in the setting of tethered oral tissues, but there may be other findings from the swallow study that could shed light on the “bigger picture”.  The ability to recruit full ROM for chewing a full variety of foods may be sensory-based, motor-based, and/or due to the impact of the altered ROM of the check/lip/lingual muscles due to tethering, and/or a combination of any of these. Take a careful re-look at oral-motor control and preferential foods/liquids to help you peel apart what might be the “why”. The sensory “load” from the foods that child is successful with, and the bolus control required, and also the co-occurring muscular requirements for posterior bolus formation and full ROM for BOT retraction, are key considerations. It’s complex, so pause to sort it out and figure out the “what else” that might be impacting what you are seeing. The apparent need for a release is clearly a factor in your differential, but like a “detective,” now focus on if there is anything else that underpins function that might be aberrant. It may be that the release planned will not in and of itself promote normal eating patterns; I suspect that is unlikely. Whether there is perhaps also learned maladaptive oral-motor behavior and other reasons for his preferences will need to be sorted out and treated to support optimal feeding outcomes.