Take a look at this recently published paper which is available Open Source:

Puri, N. B., & Sanchez, R. E. (2025). Gastroesophageal Reflux in Children. Current Treatment Options in Pediatrics, 11(1), 10. https://doi.org/10.1007/s40746-024-00321-5

The authors are well-respected and are part of the medical team at Nationwide Children’s Hospital. They discuss a medical perspective on typical pathophysiology, GER symptoms, Red Flag Symptoms and differential diagnosis in infants and children/adolescents which can inform our practice as pediatric SLPs. The information is adapted from and consistent with ESPGHAN/NASPGHAN GERD guidelines. They remind us that currently, there is not a single diagnostic test for the diagnosis of GER, and discuss the current testing considered in patients with GER and technology that hopes to advance their care and diagnostics. Finally, they address current approaches to medical management that we must be aware of when working with our medical colleagues.

Being familiar with this information can help us speak from a perspective of knowledge, whether interacting with a neonatologist, a pediatrician or an intensivist or a GI doctor. We can then respectfully advocate regarding our added and valuable therapeutic perspective that considers the whole child, sensory, volume/intake issues, day to day realities, and the interventions that the medical perspective has not yet fully embraced, sadly.

Catherine

A recent post on social media asked…..

“Has anyone been to Catherine Shaker’s seminars?

They will be in my area so I can do an in-person course.

Do you recommend?”

These are some of the responses~

• I highly recommend! I took her Advanced pediatric feeding course about 10 years ago. It was phenomenal. Catherine is a gifted teacher who has worked for decades, is a true specialist and expert clinician and has a kind spirit. She models so well how to think about clinical diagnostics, how to collaborate and with gentleness and compassion for the families. I learn something new every time she responds to questions in our FB group.
• Yes! Her course was my first feeding course and was wonderful!
• Well worth the $$!
• Yes! Her courses were foundational for me! She’s amazing
• Yes! Don’t miss it! She is a wealth of information and a talented speaker
• YES! They are wonderful courses.
• 100% recommend
• Excellent
• So good! Catherine Shaker is such a wonderful wealth of knowledge. Highly recommended!
• I went to one last Fall. Highly recommend!
• Highly recommended
• Yes! I gained so much confidence after her course.
• Went to all of them, LOVED them.
• Yes, and they are awesome!
• Wonderful courses and highly recommend.
• Yes! She’s wonderful!
• She’s excellent
• She is fabulous!

You can find years of feedback from my seminar attendees on my website under the “Testimonials” TAB via this link https://shaker4swallowingandfeeding.com/testimonials/

Click here for Catherine Shaker Seminars 2025 Brochure

Click here for Site/Location Info

……….See you in Lexington KY, Columbus OH, Walnut Creek CA, Long Beach CA, Plano TX, and Houston TX………………..

Na, Y., Choi, J., Choi, J., Oh, S. M., Jang, H., Choi, S., … & Kwon, J. Y. (2025). Videofluoroscopic swallowing study predicts clinical outcomes in critically Ill children with dysphagia: a retrospective observational study. Frontiers in Pediatrics, 13, 1507645.

Whether you evaluate and treat children in the community who may be post-hospitalization in PICU, or you work in pediatric  acute, this study will inform your practice. It provides valuable contributions to our current knowledge base by highlighting the patterns of dysphagia in critically ill children who return to community care post-hospitalization. It also highlights the predictive value of VFSS in identifying silent aspiration, and in predicting significant patient outcomes, such as the length of stay in PICU and delays in initiating oral feeding. These insights are crucial for improving the quality of care for these vulnerable children while inpatient, and after discharge home to community therapy.

QUOTE: It provides significant insights into the prevalence and implications of silent aspiration in children within the PICU setting, presenting detailed findings from VFSS. The most significant predictors of silent aspiration are age, laryngeal cleft, laryngomalacia, unilateral vocal fold paralysis, developmental delay, epilepsy/seizures, syndromes, and cardiac disease, which are common diagnoses in children in PICU. Our research builds on these findings, identifying intubation duration and the act of intubation itself as significant  predictors of aspiration risk. silent aspiration predicted a longer PICU LOS and poor oral feeding outcomes at hospital discharge. This finding not only aligns with but also builds upon the findings of da Silva et al, who reported extended hospital and PICU stays and delayed oral feeding in children with dysphagia. Our research underscores the critical role of early detection and intervention in managing dysphagia within the PICU. Early identification of silent aspiration through VFSS can facilitate and timely therapeutic interventions, potentially reducing the PICU length of stay and improving oral feeding outcomes at discharge.

Dysphagia in the PICU often increases hospitalization length and remains unresolved until discharge or beyond. By addressing swallowing difficulties early and implementing appropriate interventions, there is a possibility of reducing complications associated with aspiration, potentially leading to shorter PICU stays (and return to home and community followup) . Our study broadens the scope by including patients beyond those with PED (Post Extubation Dysphagia) , offering a more comprehensive view of dysphagia in pediatric critical care. Given that longer intubation periods and delayed VFSS evaluations were associated with prolonged PICU stays, it would be advisable for physicians to consider developing a protocol for performing a dysphagia work-up if intubation is prolonged.

ABSTRACT:

Background: This retrospective observational study aimed to investigate the features of acute dysphagia observed during videofluoroscopic swallowing study (VFSS) in critically ill children and their potential to anticipate clinical outcomes.

Methods: Administrative healthcare data of children aged 1–18 were analyzed. Data were collected from the pediatric intensive care unit (PICU) of a single tertiary medical center in South Korea between March 2019 and December 2022.We reviewed VFSS conducted on patients in the PICU who were referred by clinicians suspecting dysphagia.

Results: A total of 36 children were included in the study; 52.8% exhibited aspiration on VFSS. In this investigation, participants were provided with pureed food, liquids, solids, and a combination of solids and liquids (referred to as mixed) during the examination. Any occurrence of aspiration throughout the examination was deemed as aspiration. All individuals displaying aspiration were found to have silent aspiration. Silent aspiration was associated with a longer length of stay (LOS) in the PICU. Logistic regression analysis revealed that the time from PICU admission to VFSS and intubation duration significantly influenced LOS. Abnormal findings in the VFSS, including aspiration, delayed swallowing reflex, insufficient laryngeal closure, and residue, were statistically significant variables in determining the feeding mode at discharge.

Conclusion: This study highlights the importance of VFSS in assessing swallowing function in critically ill children. It suggests that VFSS findings, such as silent aspiration, can aid in predicting patient outcomes, including LOS and the delay in oral feeding.

Brinker K, Winn L, Woodbury AE, et al. (2025) The nutrition profile and utility of banana puree as a liquid thickener for medically complex infants with dysphagia. Nutr Clin Practice  40:227‐238

There is limited but growing evidence to support using banana puree for infants <12 months of age. Efficacy, nutritional value, and safety are key issues. Among all purees tested, banana puree has achieved the greatest thickness level and maintained that same level of thickness regardless of temperature overtime. (Brooks et al 2024, Brooks et al 2022). Thickening with bananas can allow infants with swallowing difficulties to experience  oral feeding, and can facilitate positive feeding experiences, without direct evidence of compromising safety. Banana puree has an appealing taste,  and may offer a more cost‐effective option for families than commercially branded products.

This paper is unique in that its authors reflect the team—an SLP, PT, MDs and a also a registered dietician. It addresses: Involving the physician (attending or pediatrician) in decisions about thickeners and the role of a dietician; and  the importance of the nutritional impact of banana puree. It informs our problem-solving, with the team,  about whether banana puree is the optimal thickener  for our infant patients who require thickened feedings for dysphagia. The authors also remind us as well about the critical role of  data via a VFSS to objectify swallowing physiology and the impact of thickeners, selected utensils and combine interventions. Enjoy this new addition to our evidence base. We are grateful to our SLP colleagues, co-authors Kristin Brinker and Michelle Taggart!

Here is quoted commentary from the paper. You can find the full text through open access on Google Scholar.

Nutrition is an important consideration when choosing the right thickening agent because

it may disrupt the delivery of nutrients to infants. Thickening agents can displace the

nutrition content in formula and human milk, potentially impacting feeding osmolarity,

gastrointestinal transit time, bowel movement frequency, stool consistency, and nutrient

absorption. Banana contributes carbohydrate calories without the comprehensive nutrition

density, essential vitamins, and minerals inherent in human milk and formula. Improper or

excessive use of banana puree can result in weight gain without the requisite accumulation

of vital vitamins, protein, and minerals necessary for optimal bone mineral density and lean

muscle mass gain. Fruit puree lacks essential fatty acids for optimal brain and eye

development. Introducing solid foods before four months of age  has been associated with

heightened risks of obesity, diabetes, eczema, and celiac disease. Because bananas

have a high potassium content, cautious deliberation is warranted, especially for infants

with renal disease. If renal function or potassium clearance is a concern, banana puree as

a thickening agent may not be suitable. Restricting the total banana volume to 15% of feeds

enables balanced delivery of nutrition, including essential fat and protein, mitigates

the risk of hyperkalemia, and increases likelihood of favorable gastrointestinal tolerance

without significant constipation effects. Although using up to 15% bananas

slightly exceeds potassium recommendations when fortifying formulas in some cases we

continue to recommend this limit unless infants have renal dysfunction or difficulty with

potassium clearance. This allows for optimization of both nutrition and hydration

needs in these infants. Our institution did follow the infants exposed to banana puree as

thickener, and our preliminary findings did not show that infants on banana puree

thickener had more complications than those on Gelmix (Finch et al., manuscript in

preparation). However, growth, laboratory results, and clinical presentation

should guide decision‐making for individual patients.

Managing infants with dysphagia requires a multidisciplinary team. As mentioned above, a

pediatric registered dietitian should be involved in nutrient analysis and monitoring growth

over time. Additionally, the SLP should provide ongoing assessment and work towards

safely discontinuing thickening agents as soon as possible. The SLP can guide feeding

position and bottle nipple selection. The flow rate of a bottle nipple contributes to the

infant’s ability to feed by mouth safely and efficiently and must be considered carefully

when using thickened milk. Most studies conducted to measure flow rates of various bottle

nipples have shown average flow rates using unthickened formula. They should not be

generalized with the use of thickened liquids. A recent study by Pados et al conducted flow

rate tests for seven different Dr Brown nipple types using thin (IDDSI Level 0), slightly thick

(IDDSI Level 1), and mildly thick (IDDSI Level 2) infant formula. These bottle nipple flow

rates tested with thickened liquids may be used to guide clinician decisions. However,

when making nipple recommendations, one must also consider other factors

that contribute to the safety and efficiency of oral feeding, including medical complexity,

oral‐motor control, and the infant’s integration of respiratory coordination. The use

and recommendation for thickened liquids should only be made after objective evaluation

via VFSS or fiberoptic endoscopic evaluation of swallowing providing an individualized

assessment of the infant’s response to varying nipple flow rates using various

consistencies. Feeding practice recommendations should be comprehensive,

including the appropriate level of thickened milk, bottle nipple, and all necessary feeding

interventions such as positioning and co-regulated external pacing.  Gastroenterologists

should also monitor gastrointestinal complications and other medical or surgical

interventions if the infant is not progressing as anticipated with thickened feeds.

I think many of us reading this article might find the beginning overwhelming. unless you are very into complex neurobiology. I am nerdy and I still felt that way in the beginning. But if you skim along in the early parts and hang in there until you get to about page 10, from there on you can extract key little nuggets that can inform our practice. These little nuggets I hope will help us speak from a perspective of knowledge and advocate for intervention,  and make better sense of the infant’s/child’s history before us, seeing them through a different lense.  I hope these nuggets inform your feeding/swallowing practice, whether in the NICU, EI or even in the adult world—yes, there are enduring sequelae form prematurity. Even if you don’t work with preemies, our former preemies land on our doorstep as toddlers, children and indeed adults whose presentation may be related to early cerebellar  dysfunction.

Muehlbacher, T., Dudink, J., & Steggerda, S. J. (2025). Cerebellar Development and the Burden of Prematurity. The Cerebellum, 24(2), 39. (Full text available on Google Scholar)

Here are some takeaways I found when they finally highlight the implications for function:  particular co-comorbidities increase cerebellar risk; the connection between an increased incidence of autism in former preterms and cerebellar dysfunction; the association of h/o NEC with smaller cerebellar volume; that corticosteroids for CLD — often a common form of treatment in the NICU — slows cerebellar growth (and  clinically both in the NICU and beyond, our infants with CLD seem to have the most challenges with suck-swallow-breathe coordination); the potential correlation between hypoxia-induced  white matter injury affecting cerebellar volume and complexity of dendrite formation in animal models; large PDAs resulting in altered blood flow associated with cerebellar hypoplasia and changes in cerebellar micro-structure; a prospective study in very preterm infants showed that nutrition via  breast milk compared to formula-fed milk improved cerebellar volumes; that there is increasing evidence for the importance of early brain activity for development of neuronal survival and formation of brain networks;  a follow-up study of former preterm infants with isolated cerebellar injury demonstrated on MRI at three years of age an impaired growth of several cerebral regions affecting both gray and white matter— and the impeded remote cortical development after isolated cerebellar injury was linked to domain-specific functional deficits in neurodevelopment; intrauterine cerebellar growth reaches its peak during the third trimester, from 24 weeks to around term equivalent age  —after preterm birth, cerebellar growth is still rapid, but several studies using ultrasound or MRI have reported that postnatal cerebellar growth in very preterm or extremely preterm infants is impeded, resulting in a ‘cerebellar hypoplasia of prematurity’; several neurodevelopmental outcomes at seven years including IQ, receptive language and motor function were positively associated with cerebellar volumes at term equivalent age and at seven years, and increased cerebellar growth was correlated with better neurodevelopmental outcome at seven years;  A small study compared a cohort consisting of 22 preterm infants born between 28 and 33 weeks and without major comorbidities (considered as “low-risk” for neurodevelopmental impairment) with 24 term controls–the “low-risk” cohort still had smaller cerebellar and hippocampal volumes and a smaller corpus callosum on MRI at nine years of age which correlated with worse attention and executive functions in the preterm group;  autism spectrum disorder has a high prevalence in preterm infants and core autism symptoms are associated with regional volume changes in the cerebellum; perinatal cerebellar injury is the largest non-hereditary risk for autism with a 36-fold increase while prematurity < 32 weeks still increases the risk 7-fold;  adults formerly born preterm had  persistent cerebellar dysfunction up to adulthood  in a study, even in the absence of early direct cerebellar lesions.

Question:

I am looking for information regarding how oral care is performed with infants who are no longer being provided with breast milk (donor or MOM) which in our Level III NICU is usually after 34 weeks PMA if no longer available from mother AND not yet PO feeding.  I’ve seen some facilities using sterile water and some even formula via oral swab, but looking to see what is happening out there!  Thanks.

Catherine’s Answer:

NICUs typically have policies and procedures specific to oral care administration that the nursing team follows because application to the inside of NICU infants’ mouth as oral care is considered immune therapy. Colostrum and early MOM or DBM are high in immunologic, anti-infective and anti-inflammatory factors. And we recognize, as therapists, its potential benefit for the neonate’s oral-sensory processing. Its sweet taste can provide a positive oral experience and perhaps entertain early learning; some researchers wonder if, when it is offered in a developmentally supportive way, the experiences may support sensory-motor learning, and the laying down of pathways in the brain to be recruited later.

There are options built into the P & P’s to accommodate infants who are intubated or have co-morbidities that require an adjusted pathway, and typically that also includes approved optional fluids for that NICU. When no MOM or DBM is available, some protocols I have seen then utilize sterile water. It, however, lacks the immunologic, anti-infective and anti-inflammatory properties of MOM or DBM, and has no “sensory load” for the oral-sensory environment, but neonatologists have cited its sterile nature as a benefit which is part of the “risk-benefit” paradigm that is understandably paramount in the NICU.

Perhaps talk with your neonatal nursing and neonatology colleagues in your NICU — their experience and clinical wisdom is amazing I have found—-and do a lit search — there is so much out there — to gather information you are seeking. Utilize this as an opportunity for cross-fertilization of knowledge about oral cares, partnering for a more developmentally-supportive approach if that might be an opportunity, and further-building of those relationships in your NICU that, as you know, create an amazing environment in which we can be lifelong learners.

Wishing you the beauty, blessings and joy this season brings.

I look forward in 2025 to bringing you exceptional live in-person learning opportunities in Columbus OH, Dallas TX, Houston TX, and California. Other sites in the southeastern US and the Midwest are in the works. Sign up for my blog on my website to receive notification when my finalized seminar schedule posts in January 2025.

Join me, and your colleagues to advance your clinical reasoning and problem-solving complex patients,  from fragile neonates through school-age.

…..The real voyage of discovery consists not only in seeking new landscapes, but also
in looking thorough new eyes……

All the best in 2025!

Catherine

QUESTION:

Is Alimentum formula considered a thicker formula? We have a baby that is adjusted to 37 weeks and two days and was put on the one time use Similac standard flow nipple (clear ring) that per Pados’ research is “very fast”. Our med team had nursing get nipple from our term baby floor and are using it because the Similac slow flow (yellow collar) nipple was getting plugged. However, there was a feeding when baby coughed and dropped saturation rates to the mid-80s with this faster flow nipple. I was not aware Alimentum was thicker so wanted to hear what your experiences are. I’d rather use a quality commercial nipple so at least it’s the same exact flow rate every time for starters.

CATHERINE’S ANSWER:

Alimentum is a hypoallergenic formula that is typically thinner and not typically perceived as “thicker” or likely to cause a clogged nipple. The reason for the reported observed lack of flow through the Sim Slow flow may have been the nipple ring being overly tightened, which creates a vacuum. We don’t know anything about the infant’s GA, which research tells us is more predictive of feeding problems than PMA. This infant’s history and co-morbidities may indeed profile greater risk for airway invasion with the medium flow clear ring nipple. The coughing and deep desaturations are indeed worrisome , and both are correlated with silent aspiration in the research by Ferguson. Agree a slower flowing nipple is indicated based on what we know, and perhaps other protective interventions ( swaddled sidelying, co-regulated). The Dr. Brown’s preemie flow may provide protection and avert over tightened ring. Have you had the opportunity to do a clinical assessment, and can you tell us more about history and co-morbidities? Understanding the bigger picture always helps me understand the “why” and consider both next steps and interventions more thoughtfully.

Alimentum is so super thin at baseline, that even when it is fortified 24 cal it still is quite thin and watery, in my experience. I do hear some caregivers comment that it is “thicker” when 24 cal but I suspect that is conjecture – based on the idea that typically adding something might increase viscosity. But it’s all about the baseline integrity of the fluid. Alimentum at baseline is 80% water by composition and extensively hydrolyzed, so very watery. Often, those infants who require 24-cal Alimentum have multiple possible reasons why drive to feed and volume transferred may be suboptimal. The assumed culprit is often “its thick” but, as you know, our fragile feeders often have complex underlying issues that can adversely affect feeding success.

                                                                                  This Thanksgiving, I want to share my gratitude for the opportunity to connect with you and share our common passion…safe and successful feeding.

Supporting the feeding relationship for infants, children, and their families is at the heart of what we do, and I’m thankful for the chance to be part of your journey

May your holiday season be filled with joy, love, and moments that matter most.

During 2024, I traveled from the heartland to Texas and to the East and West  coasts, and met (and re-connected with !)  some amazing people along the way. From past attendees who once again joined me in Sacramento, to the dedicated team at Wake Med Medical Center, to the amazing NICU nurses who learned along with STs/ OTs/PTs at my NICU seminar in Texas, to the staff and children at Morristown Medical Center, and the dynamic team at Community Health in Indy. From all coasts and around the world (Canada, Dubai, Spain, Japan, the UK) 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….. to Columbus OH, Dallas, Houston and California.

Sign up for my blog on my website to receive a notification when my 2025 Seminar schedule is posted.

I continue to be grateful for each of you who shares my passion for neonatal/pediatric swallowing and feeding, and lifelong learning. I hope our paths cross in 2025!

Catherine

Some of my favorite comments over the years:

“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