In our neonatal/pediatric population, often the need for TEE (Trans Esophageal ECHO),  a the surgical procedure that  involved the aortic arch, and/or both intra-operative and post-operative events —in the setting of the inherent neurodevelopmental risks for the CHD population — all raise our index of suspicion when we are re-consulted post-op.

I have been meaning to post this article by the team at CHOP for my peds colleagues who follow our infants/children with CHD. It suggests the most common risk factors associated with poor feeding for infants with Congenital Heart Disease at time of discharge were: birth weight (36% of included studies), gestational age (44%), duration of post-operative intubation (48%), cardiac diagnosis (40%), and presence of genetic syndrome or chromosomal anomaly (36%).

Jacobwitz M, Dean Durning J,Moriarty H, James R, Irving SY, Licht DJ, and Yost J (2023) Oral feeding dysfunction in post-operative infants with CHDs: a scoping review.Cardiology in the Young 33: 570–578.doi: 10.1017/S1047951122001299 (available on Google Scholar)

While pre-operatively the presence of complex co-morbidities portends for more worrisome post-op feeding challenges, in this population the well-intentioned “push” to PO feed or the “push” to return to PO feeding post-op in a regimented way, often sets the stage for volume-driven stressful feeding experiences (for infants and children alike). That can then often provoke the onset of feeding refusals and indeed aversions, and further exacerbate baseline risk for enduring feeding problems. Our partnership with the PCVICU team, including families, is so important to optimize feeding outcomes in this at risk population and support joy in feeding for a lifetime.

I hope this informs your practice as it did mine.

“The real voyage of discovery consists not only in seeking new landscapes but also in looking through a new lens.”

Join Catherine in 2024 for advanced clinical learning opportunities in Indy, Raleigh, Morristown NJ, and the Dallas area ….

• 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

An interactive welcoming learning environment……with multiple planned times for dialogue and questions, problem-solving your patients, sharing our collective wisdom, discussing the evidence-based research…and our shared clinical challenges.

Our discussions will include critical thinking for all our patients, no matter the age. It’s not just learning “what to do” clinically but thoughtfully considering what not to do and why.      Because every feeding experience matters………

Click here for Catherine Shaker Seminars 2024 Brochure

Click here for Site/Location Info

QUESTION: I am considering the Pediatric Videofluoroscopic Swallowing Studies course. I am not in the hospital setting but I go with my patients almost always to their studies. I’m thinking this is going to be super beneficial for me with advocating for patients. Often times no compensatory strategies are used, I’m told they can’t use cold or carbonated liquids, etc. When in previous settings I have known these things not to be the case. Thoughts? Am I thinking correctly that this would be helpful for a private practice SLP as well?

CATHERINE’S ANSWER: It is wonderful that you can attend the VFSS to be part of the problem-solving. Yes, the course will absolutely be valuable to you. I designed it to fill that void that is out there, as well as to support well-thought-out studies that look far beyond “aspiration” and “thickening” It is not the radiographic image alone that contributes to an impression and plan of care. The course is designed to provide the latest evidence-base regarding evolution of/progressive changes (with age) in both structural relationships and physiology from birth through the age of about 6 (based on the data and research we have), when the swallow becomes adult-like in all respects for the typically developing child. This information helps to understand where to specifically map interventions. The focus of the course is not on looking for or finding “aspiration” but on objectifying swallowing physiology (or pathophysiology), considering how that physiology may impact airway protection and relative risk for airway invasion,  and then critically considering, in the setting of that child’s unique history and co-morbidities, how to optimize safety —and objectifying potential interventions there in radiology, finally providing the thoughtful impressions that round out the picture of mealtime impact for the team. These underpinnings for critical thinking are key for any treating therapist, even if that therapist does not conduct swallow studies. Making sense of the dataset, if useful data is gathered, is not the sole domain, nor the sole responsibility of the therapist doing the study. Understanding physiology and its connection to function and intervention is essential for treating therapists too—That knowledge base makes us more effective problem-solvers and critical thinkers every step of the way. So much underpins what we do as swallowing/feeding specialists. Physiology, and the impact of pathophysiology, is at its heart.

Some feedback from previous attendees to my Pediatric Videofluoroscopic Swallow Studies seminar:

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

Catherine’s 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. Her 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. Lisa, OTR

The information presented by Catherine in the VFSS course was so well researched. I feel confident that I can add all of this info to my clinical knowledge, and I know where to find more info (via the many citations)! Kari, SLP

As an outside provider (not in a hospital doing VFSS), this was great info on how I can communicate what I’m looking for and why I’m recommending a VFSS. The time watching videos of swallow studies helped my brain process the reports I read when I can’t be at the actual study in person. Minnie, SLP 

Catherine had a great way of effectively presenting information through multiple modalities. The x-ray stills, videos of so many different etiologies and the case studies in radiology have tremendously increased my confidence with pediatric MBSS. Heather, SLP

This course gave a great perspective on how to effectively determine and describe a disruption in swallow physiology for parents, physicians and other professionals. I loved the video examples! Rachel, SLP

The swallow studies course is an excellent synthesis of the dynamic aspects of pediatric swallowing and an exquisite way to transition to VFSS. Monique, SLP

What a great course on pediatric swallow studies. Now I know to think physiology, not just aspiration and penetration!! Yeah! Samantha, SLP

I am surprised and enlightened by how much I have learned considering I have been doing pediatric VFSS’s for 15 years! Natasha, SLP

I am just starting my VFSS training, and this course will help tremendously! A wonderful opportunity to consider differentials for many different clinical presentations. Jennifer, SLP

Join Catherine in 2024 in Sacramento, Indy, Raleigh, Morristown NJ, and the Dallas area ….

• 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

An interactive welcoming learning environment……with multiple planned times for dialogue and questions, problem-solving your patients, sharing our collective wisdom, discussing the evidence-based research…and our shared clinical challenges.

Our discussions will include critical thinking for all our patients, no matter the age. It’s not just learning “what to do” clinically but thoughtfully considering what not to do and why.      Because every feeding experience matters………

Click here for Catherine Shaker Seminars 2024 Brochure

Click here for Site/Location Info

Sharing these resources for you to use as part of your differential and problem-solving when supporting infants and children with feeding and swallowing problems.

The Feeding Flock is an interdisciplinary team partnering with families to advance education, support clinical practice, and collaborate on research related to infant and child feeding challenges.

Through their new website (https://feedingflockteam.org), you can access these tools:

Early Feeding Skills Assessment Tool (EFS)

I developed this infant-guided tool with my nursing colleagues, Suzanne Thoyre RN PhD, and Karen Pridham RN PhD. It is a clinician-reported evidence-based tool with strong psychometric properties. It assesses infant feeding skills & behaviors during bottle or breastfeeding for preterm infants to 6 months. There are 19 items and 5 subscales:  Respiratory Regulation, Oral-Motor Function, Swallowing Coordination, Engagement, and Physiologic Stability. An excellent guide to cue-based infant-guided feeding in the NICU and beyond.

Neonatal Eating Assessment Tool (NeoEAT)

• Measures feeding skills & behaviors during bottle and/or breastfeeding
• 0-6 months
• Parent-reported assessment tool

Pediatric Eating Assessment Tool (PediEAT)

• Measures infant & child feeding behaviors during liquid and solid food feeding
• 6 months to 7 years
• Parent-reported assessment tool

Child Oral and Motor Proficiency Scale (ChOMPS)

• Measures observable eating, drinking & related motor skills relied upon for solid food eating
• 6 months to 7 years
• Parent-reported assessment tool

Impact of Feeding on the Parent and Family Scales (Feeding Impact Scales)

• Measures the impact of the child’s feeding on parent & family
• Birth to 18 years
• Parent-reported assessment tool

Family Management Measure of Feeding (FaMM Feed)

• Measures how families manage their child’s feeding difficulty
• Birth to 18 years
• Parent-reported assessment tool

So often, the children we follow for PFDs may have co-occurring food allergies and may show refusal/aversion, anxiety with eating, and poor intake, slowness in eating, immature diet, and delays in oral sensory-motor skills. When we complete our differentials, careful consideration of the “why” behind clinical presentation and parental report are essential.  We are sometimes the critical link in suggestions to the pediatrician that a consult be considered to further assess potential for food allergies that may have not been apparent and may be part of “why” the child has behaviors consistent with a Pediatric Feeding Disorder.

Kefford, J., Marshall, J., Packer, R. L., & Ward, E. C. (2023). Feeding characteristics in children with food allergies: A scoping review. Journal of Speech, Language, and Hearing Research. Advance online publication. https://doi.org/10.1044/2023_JSLHR-23-00303

One of my Pulmonology colleagues asked me, “Catherine, do you think it is worse to aspirate breastmilk or thickened formula?” My mind went so many directions… from relevant co-morbidities to overall clinical presentation, to history, to objective data about swallowing physiology from FEES, if there was bottle-feeding experience, and, if so, any comparative data about swallowing physiology…. and then to this latest evidence. The Pulmonologist and I had a wonderful discussion about the possible implications, and what we might take away from their results to inform our critical thinking and our practice.

Breastfeeding and bottle-feeding physiology have differences that, under certain conditions, may enhance airway protection at the breast — via the exquisite and protective swallow-breathe interface, which cannot be duplicated by a manmade nipple. We have no evidence that EBM via a manmade nipple will be as protective as EBM via mother’s breast, though it may offer a greater safety margin and less potential adverse effects than thickened formula. Perhaps more so in the setting of certain co-morbidities, or a unique infant. More data is needed to guide us, but this is certainly food for thought.

Hersh, C. J., Sorbo, J., Moreno, J. M., Hartnick, E., Fracchia, M. S., & Hartnick, C. J. (2022). Aspiration does not mean the end of a breast-feeding relationship. International Journal of Pediatric Otorhinolaryngology, 161, 111263.

ABSTRACT:

Objective: Breastfeeding is widely recommended as optimal nutrition for infants. However, there are no known publications on the impact of prandial aspiration of breast milk fed infants with dysphagia. The goal of this study was to assess pulmonary outcomes in infants with dysphagia who were given medical clearance for intake of
breast milk.

Methods: This retrospective cohort study included review of 80 infants examined between August 2016 to March 2021. Patients were evaluated by an interdisciplinary team of providers in a tertiary pediatric aerodigestive center. Patient inclusion criteria included a VFSS with documented aspiration or penetration with thin liquids. Participants met inclusion criteria if given medical clearance for intake of breast milk despite aspiration risk.
Pulmonary health was monitored for three months following medical clearance for the consumption of breast milk. Pulmonary illness was defined as development of bronchiolitis, wheezing, unexplained stridor during feeding, croup, pneumonia, or persistent bacterial bronchitis requiring medical intervention.

Results: Forty-three males (54%) and 37 females (46%) enrolled in the study with an age range of 1 month–6 months corrected age. Mean age at initial VFSS was 3.6 months. Twenty-six out of 80 (32.5%) had a report of a mild cough but did not require intervention. Eight out of 80 (10%) received a diagnosis of a pulmonary illness. Seventy-two out of 80 (90%) did not report pulmonary illness.

Conclusion: This pilot study reveals that the majority (90%) of this single institution, small sample size cohort of breast milk fed infants with documented oropharyngeal dysphagia remained healthy despite continued intake of breast milk. Prospective investigation is warranted to follow pulmonary health outcomes longitudinally and a head-to-head comparative study would be helpful to identify whether there were indeed significant changes to pulmonary health according to differential feeding regimens offered and followed.

Question: Do you know the flow rate of Avent level 1 and 2 compared to Dr. Browns flows???

Catherine’s Answer: The data you are asking about is available through the researcher’s paid access portal. Remember that your skills as a diagnostician and observer of infant feeding is the foundation for your differential and for assessing optimal flow rate, which may include objective data in radiology if indicated by your hypothesis. While the flow rate data can potentially add to that differential, your clinical impression via skilled diagnostic observation must guide you every step of the way. The flow rate data is only one piece of information – you could superimpose that on your impression and go from there. But you can still make sound clinical judgements if you do not have the flowrate data from a breast pump. There won’t always be data for every nipple in the unique setting of that infant’s co-morbidities, oral-motor control, unique swallowing physiology and nuances of RR, WOB and overall sensory-motor foundation—-which are essential considerations. Our data set from our clinical experience, and from many swallow studies with a wide variety of infants both with normal physiology (who happen to land in radiology), and with our infants with pathophysiology, together offer us data about nipple flow rate and its interaction with physiology/pathophysiology, based on our training in oral-sensory-motor, swallowing and swallowing disorders and evidence-based interventions. There won’t always be flowrate data but that should not preclude the critical thinking and reflection that underpins our differential and plan of care every time, with every infant. Step back and sort out what you understand about the infant and ask what else may be part of what is happening and stay in that “grey zone” where your clinical impressions become the pathway to interventions.

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 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

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.

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