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!

Catherine Shaker’s Indy Seminars: Take Your Practice to the Next Level!

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I’ll be in Indy in July for three advanced learning opportunities! Designed to build not just your information base but also your critical thinking for complex neonatal and pediatric patients.

  • Pediatric Swallowing and Feeding: The Essentials July 19-20
  • Neonatal/Pediatric Videoswallow Studies July 21
  • NICU Swallowing and Feeding: In the Nursery and Early intervention July 22-23

I bring my passion for feeding and swallowing to every course I teach, and I remember what it was like 45 years ago to be starting out but not know where to start. Our discussions will include critical thinking for all our patients, no matter the age or co-morbidities. It’s not just learning “what to do” clinically but also the critical thinking about “why”. We’ll take 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 require thoughtful problem-solving to peel apart.

I designed my Pediatric Swallowing and Feeding: The Essentials course to provide a solid foundation in 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 “why” behind them —to support your problem solving. I weave in the research to help you, resources to take away and integrate multiple levels of learning to build critical thinking. In the NICU Seminar, hear about the latest research and interventions, assessing and treating complex sick newborns and preterms with swallowing feeding challenges, trachs, tubes, readiness for PO, and post-CPAP/HFNC. Finally hear about how to treat those complex babies in the NICU and in an EI caseload discharged to you 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. Apply key info to treating your patients in therapy — even if you don’t actually “do” swallow studies!

I hope you can join us!




Problem-Solving with Catherine: Former Late Preterm with Stridor

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


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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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.




Catherine Shaker Seminars 2023: Real World Learning

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Join me for multiple advanced clinical learning opportunities! Clinically relevant, rooted in evidence-based practice and critical thinking. Immediately applicable. Enjoy a welcoming environment that fosters interaction and learning along with each other. Remaining 2023 locations:  Indianapolis (July), Baltimore (August/September), Yonkers NY (September), and Boston (October). This will change your practice.

  • Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Issues
  • NICU Swallowing and Feeding: In the Nursery and After Discharge in EI
  • Pediatric Swallowing and Feeding: The Essentials
  • Pediatric Video Swallow Studies: From Physiology to Analysis
  • The Early Feeding Skills Assessment Tool: A Guide to Cue based Feeding in the NICU and 

Our discussions will include critical thinking for all our patients, no matter the age. It’s not just learning “what to do ” clinically but 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 neonatologist 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 lense 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 our problem-solving.

Problem-Solving with Catherine: Where to Begin with Former Preemie with Multiple Complex Co-Morbidities

Agenesis of the Corpus Callosum (ACC) - Sonas Home Health Care


I’m looking for some insight on where to begin with this case:
The child’s age is 4 Months (Preemie Baby – 35 Weeks, will be 5 months soon). Aspiration pneumonia, G-Tube and Nissen Fundoplication, nothing by mouth.
Issues with swallowing – risk of saliva entering to lungs – can’t give him pacifier, reflux, and unknown genetic abnormality/corpus callosum. Any help would be appreciated!

Catherine’s Answer:

Sounds like he is a late preterm who is going to be 5 months soon and would then be not quite 4 months adjusted age.​ The neurologic co-morbidities (absent corpus callosum) suggest at least part of the etiology for the abnormal swallowing and that often results in altered oral-pharyngeal reflexes that underpin feeding. There may be other components of his history that might further inform a differential to guide a plan of care. I would suspect there might have been a VFSS early on in the NICU unless he was so neurologically devastated that the team determined a VFSS would not change his management and proceeded with a G-Tube/Nissen; or if he did not swallow his saliva, we would likely not do a VFSS. High risk for altered postural control so will benefit from neurodevelopmental treatment to facilitated base for supporting motor learning. Oral-sensory-motor intervention will be key to support learning to swallow saliva; this often involves using a pacifier as one component. When cautiously and thoughtfully utilized, it can help facilitate the intrinsic tongue control for swallowing saliva and oral-motor organization.

To start problem-solving, it will be helpful for me to understand what you see clinically, especially related to postural and oral-pharyngeal tone, oral-pharyngeal reflexes, interest in own hands to face/ mouth, need for suctioning and response to suctioning, any spontaneous swallows observed, any ENT consult results.

Very challenging patient with multiple complex issues that are likely to be enduring and progress likely to be slow.

I hope this is helpful.

Catherine Shaker 2023 Seminars: Reinforce Your Intellectual Curiosity!

Remaining 2023 Locations:  Indianapolis, Baltimore, Yonkers NY and Boston

When Real Learning Happens in the Brain, According to Neuroscience |

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 asks and seeks answers to the “why” questions. And doesn’t stop asking at a surface level, but instead asks probing questions in order to peel back layers of explanation to take a deep dive …..and that changes everything.

Join me for advanced clinical learning opportunities! Each of my state-of-the-art seminars is infused with the latest research and problem-solving, enhanced by my 45 years of progressive clinical experience. Interactive learning environment…planned times for questions, case discussions, anecdotal stories to help with understanding, and so much foundational research for each topic. Join us!

  • Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Issues
  • NICU Swallowing and Feeding: In the Nursery and After Discharge in EI
  • Pediatric Swallowing and Feeding: The Essentials
  • Pediatric Video Swallow Studies: From Physiology to Analysis 
  • The Early Feeding Skills Assessment Tool: A Guide to Cue based Feeding in the NICU 

Problem-Solving with Catherine: “What Else” to Consider in a Differential

Pegalis Erickson Medical


My friend was induced at 37 weeks due to concerns for gestational HTN. She had a maternal fever and leukocytosis during labor and received ampicillin. She had a vaginal birth with baby’s initial APGAR of 6 followed by 8 and 9. After birth, her baby received phototherapy for ~8 hours for jaundice and was then discharged shortly after.

Pediatrician at follow up appointment noted a “squeaky” cry and diagnosed him with laryngomalacia as well as an anterior tongue tie. He had a frenectomy done at 1 week by ENT. ENT also noted a lip tie and recommended re-assessment in 1 month.

He exhibits a “low tongue posture” and sometimes an open mouth posture when sleeping. He is gaining weight but has difficulty with establishing and maintaining latch, especially on left breast. He tends to use a “biting” pattern rather than a sucking pattern, which seems to be impacting efficiency with intake. My friend has been using cross cradle and football positions to optimize latch. He has been unable to latch in laid back position. Stridor? (“squeaking” noises) during breast feeding on the left breast > right. Baby is also exhibiting occasional episodes of apnea when coughing on secretions and is coughing with burping intermittently, which pediatrician attributed to GERD. Frequent gas and spit up. Poor sleeping during the day unless on parent’s chest of in semi reclined position. He is currently 3 weeks, 3 days old.

Her questions are:

  1. How can she help him improve his latch, especially on the left?
  2. How can she help him to reduce stridor (“squeaking” noise) during feeding, especially on the left?
  3. Are there any exercises to help him improve lingual strength and tongue to palate elevation?
  4. Any tips on reflux management without using medications?


Catherine’s Answer:

His early medical history sounds fairly unremarkable with the exception of the “squeaky voice. I find pediatricians not uncommonly “diagnose” laryngomalacia when they hear “stridor” but there can be many etiologies for stridulous voice in an infant, and its presentation (e.g., heard only during feeding, vs. heard also at rest). It is true as the pediatrician stated that the stridor may also be a by-product of responsive protective closure to EER/LPR events.

Did ENT scope the infant, and did he/she then diagnose the infant with laryngomalacia? Did ENT report seeing any erythema or suggestion of reddening of the larynx (which may suggest ongoing EER/LPR?) If so, not uncommon then for ENT to recommend some meds. Meds have been reported to reduce inflammation and irritation to tissues and restore laryngeal sensation, in some infants. I suspect ENT did not see evidence of EER/LPR, because you mentioned only the TOTs. Did the ENT clip to release the tongue tie or laser? Laser tends to have a better result. Wonder if the “low tongue posture” may be a posterior tongue tie that was missed? Or may have other etiology. The clinical behaviors you report are c/w sequelae from a posterior tongue tie as one possible etiology. The limited ROM of the upper lip (due to tethering) can also impact the entire oral-motor and hyo-laryngeal muscular network that underpins feeding/swallowing, and create the challenges being observed. Research and clinical observation have suggested a correlation between posterior tongue tie and EER/LPR (air is ingested with each suck-swallow d/t an ineffective seal with the nipple); this can be recruited at breast or bottle.

Tethered oral tissues can often co-occur with mandibular hypoplasia, and in such circumstances, if the tethering is released, it can provoke glossoptosis and airway obstruction. This reinforces the importance of always focusing on the bigger picture perspective, using thoughtful reflection and not signal reacting to a single finding, without considering the context, when we complete a differential.

What to do is not fully clear due to multiple pieces that seem to be contributing our differential (TOTs, EER/LPR, potential influence of airway/laryngeal integrity, possible mandibular hypoplasia). A clinical swallowing and feeding evaluation by a pediatric SLP with experience with complex infants is the place to start. With clinical observations there will be more questions and paths to discovery of what to do.

I hesitate to suggest strategies without understanding what is causing what, as it like shooting in the dark. The stridor may resolve with management of EER/LPR, once we understand its etiology. Ineffective tongue-palate seal and air swallowing may be reduced by release of a posterior tongue tie. There may not be a clear indication of need for lingual strengthening base on what we know so far, but there may, pending the SLP assessment. The “whys” behind each of the concerns so thoughtfully articulated need to be peeled apart to find the “what to do/interventions” that best meet this infant’s needs without a generic response about interventions “to try”. In the interim I’d be happy to talk with your friend about some possible interval inventions that might ease the feeding process. She’s lucky to have you in her corner.

For infants presenting like our little one above, my IBCLC colleagues sometimes trial a nipple shield, bodywork, craniosacral and myofascial interventions in addition to positional changes to impact the altered fascia and postural mechanism. Although it’s not optimal, if intake and weight gain become concerns with breastfeeding challenges, consideration of interim supplemental bottle-feeding has been successful via a Dr. Brown’s controllable flow nipple (a similar as possible to the controllable breast flow), adding in the blue valve (to avert energy depletion given what sounds like infant’s predominant compression-only sucking pattern). Lots of moving parts for this infant’s bigger picture that will benefit from a skilled pediatric SLP’s eye.

Problem-Solving with Catherine: Poor PO Feeding in Former 25-week Twins

10 ways to support a friend with a baby in the NICU - Today's Parent


I have not seen this family yet, but here are their concerns. They didn’t specify the babies’ current age but I’m guessing a couple of weeks out from being discharged at 44 weeks so their corrected age would only be about 6 weeks. Would love any guidance in how to best support this family!

“Twins born 25w, used to take 100ml per feed in NICU when they were 36weeks – 44weeks. Their feed has been declining since discharge at 44 weeks. Recently 30-70ml per feed, only hitting 50-70% of daily total volume goal. Both would get fussy/mad often during feed and fall asleep a lot. We have already changed the formula a couple times as suggested by our pediatrician, but they don’t seem to behave too differently. We use fortified breast milk 24 calories per oz with the formula. Started with Neosure (used in the NICU), tried Enfacare for a few days, and changed to Nutramigen for the last two weeks.”

Catherine’s Answer:

We don’t know much about history but hearing that they are former 25 weekers suggests strongly to me that there is a high risk for respiratory sequelae, which may be why they are disengaging during feeding; it is likely purposeful and adaptive behavior. There may be GI issues that could be related to many possibilities—such as gulping leading to air ingestion, tethered oral tissues that create air ingestion with each suck – both possibilities could provoke GI discomfort.  Parents may have increased the nipple flow rate since being home (to increase intake) which may be actually reducing their available breaths and leading to depletion of reserves and making intake worse. It’s all about the aerobic demands of feeding and the co-morbidities that underpin function. And it is also possible the intake noted in NICU was due to well-intentioned volume-driven feeding, sadly, and maybe now parents – hopefully- aren’t “pushing them”. When you evaluate the infants, be watchful for infant communication (physiologic and behavioral stress signs), how parents feed (flow rate, position, consideration of state, their response, or lack of response to infant disengagement, how developmentally supportive the feeding experience is – or is it volume-driven, what they describe would be a “good feeding” (i.e., bottle empty, awake at the end, stays awake, seems to like it). May experience tells me that volume-driven feeding combined with respiratory fatigue may be what’s going on. Parents will then need gentle (and the “whys” behind your suggestions) to unwind that volume-driven approach and move to infant-guided feeding (more manageable/slower flowrate, swaddled elevated sidelying, contingent resting, contingent co-regulated pacing). Close contact with the pediatrician will be essential. Re-admissions due to FTT post NICU discharge are high in this group, who often present as fragile feeders in the NICU and after discharge too. There is also a high risk for silent and symptomatic aspiration in this group, which may also be a part of the bigger picture adversely affecting feeding.



Catherine Shaker Seminars 2023: Real Time Clinical Problem-Solving

Instructor brain

Join me for multiple advanced clinical learning opportunities! Clinically relevant, rooted in evidence-based practice and critical thinking. Immediately applicable. Enjoy a welcoming environment that fosters interaction and learning along with each other. Remaining 2023 locations: Indianapolis, Baltimore, Yonkers NY, and Boston.

  • Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Issues
  • NICU Swallowing and Feeding: In the Nursery and After Discharge in EI
  • Pediatric Swallowing and Feeding: The Essentials
  • Pediatric Video Swallow Studies: From Physiology to Analysis
  • The Early Feeding Skills Assessment Tool: A Guide to Cue based Feeding in the NICU and 

What you colleagues are saying: “This was the first “advanced” course I’ve attended that did not waste time reviewing “beginner” info. Most advanced courses do not provide functional therapy ideas or go into such high-level detail and with different evidence-based approaches in such a dynamic way” Anita, SLP

“Real time clinical problem-solving and how I can take pieces from a variety of approaches and individualize them for the infants and children I treat. Loved the group discussion and the up-to-date research”. Stephanie, OTR 






Problem-Solving with Catherine: Two-Year-Old Gagging with Textured Foods

hand puzzle


I have a 2 year 6-month-old child who was NPO and G-tube dependent until he started feeding therapy again about 5 months ago. He is safely able to consume thin liquids and IDDSI level 4 solids like pudding with no issues. Recently, I’ve started to try textured foods with him. I’ve noticed that he will accept the food into his mouth and chew it up, however, starts gagging shortly thereafter and spits it out. I don’t believe it’s a swallowing issue, but rather a sensory issue and it seems the texture of chewed up food makes him uncomfortable. Does anybody have any advice/tips on how I can help him with consuming textured foods? TIA!

Catherine’s Answer:

To help problem-solve, can you round out the bigger picture, as that is likely key to first understanding the “why” behind what he is doing, to then figure out interventions. At 2 years 6 months, is there a history that will help explain some of this? For example, why was a G-Tube placed? Was he born at term? What are his diagnoses? GI issues? Sensory Processing Disorder? Does he have atypical motor and/or postural and/or sensory-motor issues? Cognitive/communicative status? TOTs? h/o “release” of TOTs? Clarity of connected speech? Was there ever swallow study and what did it reveal about physiology? Is he gaining weight? One of my colleagues wondered if there may be any tonsillar hypertrophy that could create challenges with textured foods; any apparent challenges with thicker purees that may suggest that etiology as well?  It’s very possible that his responses are adaptive behavior, i.e., purposeful, and due to reduced strength and motor control problems. If so, that will be your treatment focus. You are asking good questions. It’s ok to take the time to figure out the why and ask yourself more questions about what you are seeing and the possible reasons. Otherwise, you may select interventions that are not what his system needs, and more maladaptation could be inadvertently fostered.

Problem-Solving with Catherine: Prolonged Pacifier Use in 4-year-old

pile of pacifiers ready for the pacifier fairyQuestion:

I have a 4-year-old who unfortunately has demonstrated significantly violent behavior with parents’ attempts to wean him. He has been significantly impacted on a structural level by prolonged use, negatively impacting both speech and feeding. My gut tells me it needs to be addressed by pediatric psychology.

Catherine’s Answer:

There are likely multiple factors contributing as this is atypical for an otherwise normally- developing four-year-old. What else do you know about his history and co-morbidities? That gestalt will likely offer some key insights that may be relevant.

It is possible the structural differences you observe are a consequence of prolonged pacifier use, but the structural differences may also be co-occurring. Meaning that the structural differences may be separate from the impact of a pacifier and unrelated in their etiology. Or they may indeed be solely due to prolonged pacifier use or exacerbated by it. Understanding any history or co-morbidities that are a part of his “bigger picture” would help peel that apart. As Barb so thoughtfully suggested, there may be reasons from a sensory motor perspective that pacifier use serves “a purpose” for him, meets a “need’ on a sensory level, as our kids at all ages do things for a reason. That may provoke the unbridled response reported when the “answer” to his “need” is taken away. Or it may be a learned behavioral response established in the child-parent relationship.

Without knowing his history and co-morbidities, it is challenging to problem-solve but with what I understand, there is a need for the expertise of pediatric SLP related to feeding and speech. Prolonged pacifier use can alter the oral-motor synergies/components that underpin chewing, swallowing and speech production. I’d suggest a consult by a pediatric OT skilled in sensory integration. The OT will also assess overall sensory motor control/processing, which may be the part of the underlying need that pacifier use is serving and determine if a PT consult is warranted.

At his age there may be a learned behavior and interaction pattern with parents, both related to pacifier use and beyond, that would benefit from the additional expertise of a pediatric psychologist.

Then the three professionals can together problem-solve and develop a plan of care with family involvement that addresses the “why” (postural, sensory-motor, oral-motor, “behavioral”) and a systematic approach to providing, in other ways, what his sensory system needs or “is craving” That may include SLP support for oral-sensory-motor treatment to normalize his oral-sensory system, and promote carryover of that intervention in ways that are more socially acceptable (and more developmentally supportive) than a pacifier, and OT for sensory integration that is perhaps more of a global need for this child than apparent on first glance.

I hope this is helpful.

Catherine Shaker Seminars: Take Your Practice to the Next Level!

2023 Locations: Miami, Indianapolis, Baltimore, Yonkers NY and Boston

How can dialectical thinking help you? | MHT

Join me for an exceptional learning opportunity!

  • Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Issues
  • NICU Swallowing and Feeding: In the Nursery and After Discharge in EI
  • Pediatric Swallowing and Feeding: The Essentials
  • Pediatric Video Swallow Studies: From Physiology to Analysis 
  • The Early Feeding Skills Assessment Tool: A Guide to Cue based Feeding in the NICU 

What your colleagues are saying….  ” It’s nice to know that even experienced therapists don’t have all the answers and need to problem solve and dialogue with others. I liked Catherine’s discussion “system-based thinking” when trying to differentially diagnose the reason why something might be happening. Loved the increased confidence this course gave me! It filled in lots of gaps.”  Violet, SLP


Catherine’s Research Corner: Congenital Heart Disease and Nutrition

Baby's Heart-lung System by Pixologicstudio/science Photo Library

For those of you working with infants with CHD, this is a great resource which includes a primer on CHD pathophysiology and nutrition needs. These infants are among our most fragile feeders, at risk for aversions and failure to thrive. The more we understand normal and altered structure/function of the heart, and the impact on nutritional needs and feeding, the more informed our clinical reasoning and our engagement with the team will be. So essential to supporting infants and families in both acute care and after discharge in early intervention. Here is the secure link from Nutricia Learning Centers:

roundtable journal discussions overview (