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


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.


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










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: Supporting Intubated Infants

Mum's Horror As Baby Is Placed On Life Support After Swallowing Caustic ...

Question: During rounds there was a question around whether there were any benefits to providing oral stimulation for our intubated NICU infants. I did a quick search to see if there was any literature out there but did not find anything specific to intubated infants. Interested in your insights and experiences.

Catherine’s Answer:

Early oral cares are often provided by bedside RNs in this fragile population of intubated infants, and research documents multiple benefits. A few added thoughts related to our clinical wisdom. The population of “intubated infants” in the NICU as you know encompasses such a wide range of GA, PMA, co-morbidities and levels of physiologic stability and tolerance to interventions.

These indeed are often our most fragile NICU infants. Each one is typically unique, so I always start with understanding that infant’s co-morbidities that led to the need for ventilation. For example, PPHN, CLD, CHD, congenital malformations, neuromuscular disorders, and structural airway alterations, or multiple complex co-occurring co-morbidities, which then often create an even higher risk for adverse feeding outcomes.

Bobbi Pineda in her most recent contribution to our knowledge base reminds us that in the NICU we must be thoughtful and cautious, as we can inadvertently cause harm—- “Careful consideration as to whether each intervention can be done for most infants at a given PMA is complex, and vulnerability of infants in the real-world context must be carefully evaluated.”  To her nugget of wisdom, I would add “the infant’s unique co-morbidities” as critical considerations. They often profile relative overall medical complexity, medical acuity and risk for instability, adverse outcomes, and delays in progression to full PO feeding.  Research has shown that prolonged need for ventilation in preterm infants is a significant predictor for feeding outcomes (Malkar, et al 2015).  We may follow those preterm infants with prolonged need for intubation (greater than 30 days), those intubated stable preterms  approaching the PMA when feeding readiness might be considered, those with prolonged intubation waiting for placement of a tracheostomy for long term ventilation. We may also follow intubated early term, full-term and post-term infants, with their attendant sequalae secondary to co-morbidities leading to admission to the NICU, who are therefore at risk for altered progression to PO feeding.

Fragile preterms if not born early would be fetuses experiencing motor learning and oral-motor learning in utero; their oral-motor movement patterns would be evolving in the context of the containment provided by the uterus, with hands on their face and in their mouth (and alternating touching the placenta per research).The risks for our sick newborns are likely related to altered motor learning (extrauterine and potentially intrauterine) and nosocomial and developmentally-related environmental differences specific to that NICU that may support, or not support, the early oral-sensorimotor underpinnings for eventual PO feeding.

Ideally the neonatal therapist would have standing orders in a level III and Level IV and collaboratively work with the team, especially the bedside nurse, which would then best allow for this dynamic individualized, at times necessarily episodic, intervention —to support those underpinnings.

We then recognize that what interventions are offered, and what are not offered will both be critical—and be unique to that infant’s bigger picture, and the ongoing tolerance of that infant in our hands.

Interventions will involve infant-guided structuring of experiences that most closely align with the optimal oral-sensory-motor environment, which mimics to some extent a variation of those in the intrauterine space (for preterms) and those typical of early life (for sick newborns), laying the groundwork for caregivers’ embracing the complexity of the prerequisites for potential future PO feeding, and building the appreciation for the small steps that are designed to build forward in a thoughtful individualized way—which is key.

While we do not to my knowledge have RCTs to support intervention with these fragile infants, our clinical wisdom and experience clearly support that beginning to unfold this pathway to optimize outcomes has been beneficial.

Almost 15 years ago, one of our APRNs asked me to follow a former 24-week infant with CLD and PPHN, then 45 weeks adjusted age with protracted ventilator dependence. She said, “I hope you don’t think I am crazy since he is still on the vent, but I want to give him every chance to be ready and do his best if he is able to PO in the future. I think you could give him the best chance.” I recall telling her, “Thank you so much for being so proactive and seeing the possibilities to build his oral-sensorimotor readiness and minimize maladaptive behaviors. I’ll be careful every step of the way”. And she said, “Just what I thought.” That is team collaboration on the infant’s behalf.

While we don’t always have published research for what we do in the NICU, we do have our critical thinking, and the cross-fertilization of knowledge through collaboration with a thoughtful NICU team.

I hope this is helpful.

Pineda, R., Kellner, P., Guth, R. et al. NICU sensory experiences associated with positive outcomes: an integrative review of evidence from 2015–2020. J Perinatol (2023)

Malkar et al (2015) Antecedent predictors of feeding outcomes in premature infants with protracted mechanical ventilation. Journal of Pediatric Gastroenterology and Nutrition61(5), 591-595).


Problem-Solving with Catherine: PICU patients on HFNC and PO Considerations

Ask Us Anything About… RSV in Children - Penn State Health News

Question:  On our Pediatric Unit (age Newborn to 18 years), particularly Pediatric Intensive Care, our physicians are not on the same page as to WHEN to start PO trials for Peds patients, when on HFNC.  One Intensivist has ordered Eval on kids at 8L and wants us to proceed.  Other Intensivists are stating 6L or less, and our pediatricians want 4L or less.  I want an evidence-based guide for ALL STAFF to be on the same page, including the nursing staff. With a high level of admissions in PICU for this current Respiratory Season, this is coming up way too often.   Most of our nurses prefer the 4L or less, and really trust and allow Speech to make the call on appropriate level, considering the whole evaluation process.  I have one ROUGE nurse, however, that follows infant “cues” only, and doesn’t seem to consider other contributing factors; thus, she just loves when ST is not around and she will get the MD to order a Nurse Swallow Screen, and plop them on the bottle or breast, no matter what the mechanism or Level of O2 support.  I want to establish a more “black and white” approach, or perhaps at least an algorithm or flowchart for reference for ST to use in our decision making.


Catherine’s Answer:  This dilemma is a common and daily challenge for those of us who work in a Children’s Hospital, both in PICU, our peds units, Pediatric Cardiac Intensive Care and the NICU.

The evolving science about the impact of respiratory support on the swallow-breathe interface is sparse and more robust for our NICU population, yet that too is actually still in its infancy, as a guide for our clinical practice. To some extent, the NICU population has more common etiologies and co-morbidities that may allow some guiding tenets to assist us, but even so, each infant is an individual patient for whom algorithms, without carefully considering the unique nuances of that infant, can lead us down a pathway that may inadvertently be problematic and unsafe.  In addition, we have multiple caregivers in PICU both within physician specialties and our nursing colleagues who bring their unique experiences, training, and perspectives on the critical factors essential to optimize the safety PO intake in children requiring intensive care.

For each patient in PICU, multiple factors will influence our impressions, our recommendations and our thoughtful conversations with the team—-i.e., the nature of our PICU patients –with their often multiple complex co-morbidities (or lack of premorbid co-morbidities when otherwise normally developing), whether they have a history of previous hospitalization and why, their varying reasons for admission, their different trajectories in terms of where they are at in recovery from (or resolution of) the event or events that provoked admission, their respiratory history, their feeding history; the need for early yet well-timed instrumental assessment for objective data about the impact of respiratory support on swallowing physiology—avoiding a study executed too early that may create and artifact in the data set. These factors that underpin critical thinking, and our differential and plan, are not easily mapped into an algorithm. One of my neonatology colleagues refers to this as the art and science of medicine, and I suspect the consideration includes the work we do as well. A gifted caregiver, he always says we have algorithms but remember to pause to really “look” at your patient every step of the way. I love that mantra and use it every day.

A focus on patient specific factors will be key: premorbid and current co-morbidities, acuity of illness, trajectory of their medical course (are they weaning support? How smooth has weaning been thus far? Has there been need for escalation? What about the last 48 hours?), your clinical impression of prerequisites for tastes or PO trials – or current resolution of interval clinical concerns—that underpin readiness to PO), the potential risk for that child if aspiration occurs and how that might impact overall recovery. Then we have to use a dynamic cautious co-regulated approach at all ages with continuous multisystem analysis and collaboration with the team.

There will always be those caregivers in any discipline who choose to operate outside the team, whom you described as rogue; rules and algorithms likely won’t change their ways of interaction. While it may seem a black and white process would be a good fix, it doesn’t allow for the required daily dynamic thinking unique to caring for a PICU patient that is changing and whose course is evolving. I think the thoughtful “cross fertilization of knowledge” as I like to call it, among team members caring for that patient via dialogue at Rounds and at each consult and, most importantly, in our many casual conversations with our PICU colleagues in between patients, that builds a foundation for caring for each patient uniquely every time. That can still be evidence-based, which of course includes the professional knowledge base each discipline brings to the conversation but allows room for a dynamic approach to each patient moment to moment, and collaboration. That way, through this cross fertilization of knowledge each of us grows and learns, and our combined perspectives can be mulled over and considered in concert with each other. Once a patient care process such as this is set in motion, it is amazing how it fosters collaboration, partnership, and professional courtesy that then can lead to optimal outcomes for the child and family.

An algorithm cannot encompass all components of a patient’s gestalt nor consider all the potential “whys” that might be relevant to that unique PICU patient. We out of necessity need to leave some room in our dynamic plan of care to accommodate that and build on the team’s joint perspective. It’s no different that our PICU Intensivists who likely have some guiding tenets for caring for a child with TBI, but the dynamic treatment will be carefully adjusted day by day based on the current data set —there is no one algorithm for intensive care processes with a TBI, as that may be an infant post shaken baby event, or a previously normal 10-year-old, or a toddler with premorbid ASD. We do often find that those children who have been otherwise normally developing prior to being admitted, for example with an acute respiratory illness or a viral process, may experience more rapid resolution and follow the trajectory for recovery of an acute process. Those with premorbid co-morbidities or with an acute on chronic respiratory process will typically take a different path and require more caution and deliberation along the way.

Part of the passion for PICU care for all disciplines comes from the deliberation, the joint attention, the learning from each other, the discussions and the incidental learning that takes place every day. Living in the “grey zone” where the answers are not black and white, and the path is built on asking questions, and follow-up questions, not having immediate answers, is what brings us back each day to grow and learn along with our colleagues, and from each patient collaboration, and then the team takes away “key learnings” to build the clinical reasoning for the next patient.

Two recent references:

Rice, J. L., & Lefton-Greif, M. A. (2022). Treatment of pediatric patients with high-flow nasal cannula and considerations for oral feeding: a review of the literature. Perspectives of the ASHA special interest groups7(2), 543-552.

Raminick, J., & Desai, H. (2020). High Flow Oxygen Therapy and the Pressure to Feed Infants with Acute Respiratory Illness. Perspectives of the ASHA Special Interest Groups5(4), 1006-1010.

Catherine’s Research Corner: Outcomes of Extremely Preterm Infants Requiring Tracheostomy

Kayleigh's Story: 2/2/09 Post Tracheostomy Surgery

Sharing a new publication about the long-term outcomes for extremely preterm infants (born <28 weeks’ gestation) requiring tracheostomy. The persistent system-wide outcomes are not directly related to the trach but are due to the complex co-morbidities that lead to the need for a trach early in life, in the setting of prematurity.

Teplitzky, T. B., Pickle, J. C., DeCuzzi, J. L., Zur, K. B., Giordano, T., Preciado, D. A., … & Pereira, K. D. (2023). Tracheostomy in the extremely premature neonate–Long term outcomes in a multi-institutional study. International Journal of Pediatric Otorhinolaryngology167, 111492.


Extremely premature infants who underwent tracheostomy between January 1, 2012, and December 31, 2019, at four academic hospitals were identified from an existing database. Information was gathered from responses to a questionnaire by caregivers regarding airway status, feeding, and neurodevelopment 2–9 years after tracheostomy.


Data was available for 89/91 children (96.8%). The mean gestational age was 25.5 weeks (95% CI 25.2–25.7) and mean birth weight was 0.71 kg (95% CI 0.67–0.75). Mean post gestational age at tracheostomy was 22.8 weeks (95% CI 19.0–26.6). At time of the survey, 18 (20.2%) were deceased. 29 (40.8%) maintained a tracheostomy, 18 (25.4%) were on ventilatory support, and 5 (7%) required 24-h supplemental oxygen. Forty-six (64.8%) maintained a gastrostomy tube, 25 (35.2%) had oral dysphagia, and 24 (33.8%) required a modified diet. 51 (71.8%) had developmental delay, 45 (63.4%) were enrolled in school of whom 33 (73.3%) required special education services.


Tracheostomy in extremely premature neonates is associated with long term morbidity in the pulmonary, feeding, and neurocognitive domains. At time of the survey, about half are decannulated, with a majority weaned off ventilatory support indicating improvement in lung function with age. Feeding dysfunction is persistent, and a significant number will have some degree of neurocognitive dysfunction at school age. This information may help caregivers regarding expectations and plans for resource management.


Problem-Solving with Catherine: Essentials for Pediatric Dysphagia Practice

How to Develop Whole Brain Thinking?


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.

Problem-Solving with Catherine: Complex Infant Post-HIE


I have a baby who was born around 38 weeks GA, now about 3 weeks old (I can confirm when I’m at work tomorrow if needed). Attempted vaginal delivery, but baby began having HR decels. Emergent C-section, mother’s uterus ruptured, and infant was free floating in the abdominal cavity. Coded at 10 min life, resuscitated. Whole body hypothermia protocol for 3 days, then re-warmed. Inconsistent gag reflex, poor secretion management (although improved significantly), no rooting reflex, no sucking reflex. Now on RA. With the exception of improved secretion management and stability on RA, there has been no improvement. Received G-tube yesterday. Likely will go home later this week.

Parents are amazing and I’m wanting to give them everything I can. I’m putting together a packet of information on including tube fed children in family meals and preventing oral aversion, things like that.

I’m just looking for any good handouts or information anyone may have that I can use. He’ll be set up with outpatient, but the family will do anything that may help at all.

This is the first baby I’ve worked with that has had absent rooting and sucking, so I feel stuck on how to treat.

Catherine’s Answer: 

In my experience, sounds like moderate-severe HIE given the impact on oral-pharyngeal reflexes. What did MRI Brain show? That is essential to our differential. What does OT say about postural tone and movement since it is a base for oral-motor control? Likely diffuse postural hypotonia but may be starting to show some atypical movement patterns and an abnormal increase in tone, depending on MRI. In the setting of neurologic co-morbidities as devastating as this appears to be, the diminished pharyngeal responses (i.e., inconsistent gag response) reflects pathology. Would suspect that if pharyngeal responses are inconsistent, there is a co-occurring impact on pharyngeal constriction, and saliva swallows are impaired to some extent. Remember that the suck, swallow, and pharyngeal responses are underpinned by cranial nerves with overlapping function —so most often, the suck, swallow and pharyngeal are impacted to a similar extent. There is a good chance he is aspirating his saliva silently, as he may lack the sensory registration and motor responses to elicit a timely and effective cough. Sounds like you been seeing the infant in the NICU, and he is being discharged to EI/home? These infants with this level of neurologic insult are so sad and are so complex. I remember the first one I was consulted on way back in the early 90s – we did not call it HIE back then but that is what it was. Despite 10 years in EI at that time with complex infants, no one knew how to help these infants that started to survive a difficult perinatal course. That is one of the reasons that I later developed my NICU Swallowing and Feeding and After Discharge seminar, and my Advanced Infant/Pediatric Dysphagia seminar —-to share my discoveries and support clinical problem-solving of our complex patients, across the age span. The aberrant oral-pharyngeal reflexes and facilitating the sensory-motor components that will support eventual function become the focus both in NICU and EI. For parents right now, it’s all about providing motor learning during their interactions —provide infant with good postural support and midline stability with UE/hip/knee flexion, chin tilting down, via very very secure swaddle; elevated sidelying cradle turned toward caregiver with hands supported near face; facilitate rooting response on own hands and via mother’s finger using deep pressure (not expecting him to respond but focusing on providing input for the brain); firm deep pressure to blade of tongue in rhythmical one per second pattern to provide motor learning for future sucking (using his own fist, mother’s finger, firm pacifier). Lots that we can then offer as therapists via NDT, sensory-motor learning, oral-sensory interventions for developing underpinnings for rooting, non-nutritive sucking, effective saliva swallows and state regulation. These babies are complex and teach us so much! Hope this gives you a place to start. I look forward to seeing you at one of my seminars, where I can expand on these interventions.


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


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.


Problem-Solving with Catherine: 2.5-year-old with DiGeorge Syndrome


DiGeorge Syndrome/VCFS/22q deletion: My Landon's Story. Awesome read ...


I have a 2.5-year-old preschooler with DiGeorge syndrome. He spent the first few days of his life on a respirator and when he was able to come off of the respirator and drink from a bottle, he would throw everything up. They put in a PEG due to aspirations and he was put on steroids to help with vomiting. Now, he is able to eat all textures of liquids and solids without aspirating but he refuses to put anything in his mouth (he is probably traumatized from his eating difficulties). I have been working with him for a year on having positive experiences with food and educating the parents about reducing the pressure for him to eat while still showing him positive experiences with food. He has made very little progress and recently started putting his fingers in his mouth to make himself vomit after every meal. Does anyone have any recommendations of what I can do to help this little guy?


Catherine’s Answer:

I am assuming the data about “able to eat all textures without aspirating” is from a recent swallow study? Was there any information about what they saw regarding his swallowing physiology to “round out” the impression from the VFSS? While they may not have witnessed aspiration during the study, his swallowing physiology may indeed predispose him to airway invasion. I ask because it is unlikely that the typical sequelae from a DiGeorge diagnosis have all resolved (e.g., oral-motor, craniofacial, cognitive, sensory, sensory-motor, respiratory for example). The data that they did not witness aspiration during the swallow study is likely just one piece of the puzzle. Is he followed by OT and PT? Is GI following? Go back to the drawing board and take a second look at him –his clinical presentation — separate from what you know about his “not aspirating” from the swallow study, and see what pieces stand out as problematic for GI comfort, prerequisites for PO, possibly learned behavior, and what questions you want to ponder as you consider next steps. These little people with DiGeorge are so complex, and changes will be slow, challenges with feeding are often enduring. Even with being off the vent and on RA now, he may still have some breathing/airway/coordination issues with solids and liquids that continue and are roadblocks, both related to co-morbidities and also related to learned behavior. Good that you are helping the parents pump the breaks on PO. They may view him as ready to eat and they likely don’t realize there is so much more required than just “not aspirating” during the VFSS to allow safe and successful PO, given his bigger picture.