Problem-Solving: Aspirating 4 month old

Question: “Asking for a fellow therapist. What would you use to measure the effectiveness of vital stim on a 4 mo old who is aspirating severely due to a discoordinated suck – swallow. Other than using a stethoscope to listen to her lungs or if fluid is entering her stomach, I’m not sure how in a home setting we measure effectiveness. She ate a 3 ounce bottle in 15 minutes when I was there so amount of time doesn’t seem appropriate”

My response:

There can be so many etiologies for why an infant has suck-swallow-breathe incoordination. Depending on the infant’s history (was there prematurity? was she a sick newborn?) and medical co-morbidities (neurologic? respiratory? airway? GI?) as well as developmental co-morbidities (postural control? oral-motor? sensory? ),  the interventions selected will be different and specific to that etiology.

Sometimes it can seem helpful to just “find a tool”, like a NUK brush or a popular bottle or a marketed option, and then use it to “make the feeding better.” But that doesn’t work.

Don’t try to find an answer, ask more questions. Take the time to” look at” and listen to and “feel” the baby when she is feeding so you can figure out why she is “not coordinating”

Slow flow nipples, co-regulated pacing, resting, changes in positioning and guided participation with caregivers can  enhance both intake and quality of feeding, when provided by a  SLP with expertise in infant feeding/swallowing. But only after knowing why you would be using them.
Maybe Vital Stim is not an appropriate intervention, given her history, clinical presentation and your assessment. You need to find out and to ask the questions.

If feeding is new to you, seek out a colleague to work alongside you that you can learn along with. The infants we see today are quite complex for all of us.

It is quite rare  that a tool is the answer — a tool is only useful when preceded by critical thinking about why. Too often, grabbing, for the “tool” is like grabbing for a cookbook —  and its stifles your thinking. Remember cookbooks were made for cooking not for feeding.

Step back, take a deep breath and  look at the baby through new eyes. I bet you will start to answer some of the questions I posed and you will have more questions of your own about what your observations and her behaviors might mean. Then you think some more, ask more questions. Seek out a colleague’s eyes to look along with you. Then think some more with that colleague .

I know you were hoping to have someone just provide a protocol, but I am hoping instead you will let yourself think and live in the “grey zone” as I like to call it  (where answers are not quick and one must be ok with not being sure, not have answers, need to ask more questions, ask “what else” do I need to consider), because that is how one becomes a more skilled clinician.

Also need to think about: why she is aspirating? What is the etiology?

There are multiple possible reasons along the swallow pathway that can lead to maladaptations and bolus mis-direction in the context of her unique history and clinical presentation.

When was the instrumental assessment done? was the infant at her best then? has she changed since then in ways that might affect swallowing/feeding function? is there need or PT and/or OT  or other medical specialists to help sort out the “why”? is she otherwise normally developing?…. I ask all this because, as you know, we don’t treat the problem, we treat the infant.

Without understanding why she aspirated we are likely going to “throw a bunch of  interventions at the problem” and they may be inappropriate, ineffective or ill-advised, given what is really going on and the bigger picture.

I hope this is helpful.


Join us for The Early Feeding Skills Assessment Tool: A Guide to Cue-based Feeding

Please plan to join Dr. Suzanne Thoyre and I on October 12-13th,  2019 in Columbus OH at Nationwide Children’s Hospital for a Train-the-Trainer session on  The Early Feeding Skills (EFS) Assessment Tool: A Guide to Cue-Based feeding in the NICU . 

Bring yourself, your colleagues, or your whole feeding team! We are aiming for an interdisciplinary-professional group, putting our heads together to improve feeding experiences for our most vulnerable infants. We hope to see you in Columbus! 

Learn to use the EFS to effectively plan and provide an infant-guided approach to feeding.

Simultaneously learn to train others back home to use the EFS to strengthen your unit’s feeding care. Review current research, the role of experience, dynamic systems theory, and feeding outcomes after NICU. Videotapes with enhanced audio of swallowing and breathing to learn key skill areas of the EFS: respiratory regulation, oral motor and swallowing function, physiologic stability, engagement, and change in coordination patterns of s-s-b as infants develop. Gain confidence scoring early feeding skills as not yet evident, emerging or established. Learn components of an infant-guided, co-regulated approach to feeding and contingent adaptations that make this approach so effective, using the EFS to plan individualized interventions. Receive teaching resources to take back to your unit to train others to use the EFS. As a group, we will network and navigate challenging issues and role-model a collaborative feeding practice.

The EFS provides a means of identifying, for individual preterm infants, areas of strength and areas in which support is required to accomplish safe and effective feeding. All too often during oral feeding, infants experience multiple episodes of oxygen desaturation, increased energy expended in response to stress, and fatigue. Possible negative sequelae of recurring stress are often unnoticed, disregarded, or minimized. Through developmental conceptualization of specific infant feeding skills, the EFS provides an infant-focused framework for planning individualized interventions.In addition, the EFS provides a means for assessing infant readiness to engage in oral feeding and for evaluating infant response to a feeding, including any interventions employed.

Assessment and intervention are integrated functions. As infants are fed and their capacities assessed, caregiver behaviors and assessment foci must be adjusted for the individual infant. If he stops sucking spontaneously only on occasion, for example, the infant probably needs a brief imposed break from sucking to support regulation of breathing and to prevent fatigue and/or physiologic dysregulation. If the infant does not root when his lips are stroked, indicating lack of readiness to feed, the feeder explores reasons for this. If the infant has difficulty coordinating swallowing and breathing, the feeder is more alert to his capacity to manage the bolus of fluid given the frequency of sucks and the duration of sucking bursts. The feeder will want to help prevent abbreviated or missed breaths for the infant, to listen more closely for complete and safe swallowing, and to explore the need for a sidelying feeding position, low-flow nipples, pacing strategies, or more extensive swallowing evaluation by a pediatric therapist. Thorough and ongoing assessment is an essential component of feeding practice, particularly for infants early in their skill development. 

Not only does the EFS provide a pathway for your NICU team to infant-guide feeding , but it also has been shown to have strong psychometric properties for use in research. See:  Thoyre, S. M., Pados, B. F., Shaker, C. S., Fuller, K., & Park, J. (2018). Psychometric Properties of the Early Feeding Skills Assessment Tool. Advances in Neonatal Care, 18(5), E13-E23.




Research Corner: The Need for Psychometrically Validated Feeding Assessments in the NICU

Does the Infant-Driven Feeding Method Positively Impact Preterm Infant Feeding

Outcomes? Margaret Settle, PhD, RN, NE-BC; Kim Francis, PhD, RN, PHCNS-BC

Settle, M., & Francis, K. (2019). Does the Infant-Driven Feeding Method Positively Impact Preterm Infant Feeding Outcomes?. Advances in neonatal care: official journal of the National Association of Neonatal Nurses, 19(1), 51-55.


Background: Achievement of independent oral feeding is a major determinant of discharge and contributes to long lengths of stay. Accumulating evidence suggests that there is great variation between and within newborn intensive care units in the initiation and advancement of oral feeding. The Infant-Driven Feeding (IDF) method is composed of 3 behav­ioral assessments including feeding readiness, quality of feeding, and caregiver support. Each assessment includes 5 categories and is intended as a method of communication among caregivers regarding the infant’s

Findings: There were no randomized control, quasi-experimental, or retrospective studies utilizing the IDF method. There were 3 quality improvement projects utilizing the IDF method. The findings were conflicting: 1 project found the IDF method favorable in the achievement of full oral feedings, 2 projects found the IDF method favorable for reducing length of stay, and 1 project did not find differences in initiation, achievement of oral feedings, or length of stay.

Implications for Research: Research is needed to empirically validate the IDF method and to inform practice related to the initiation and advancement of oral feeding for preterm infants.

Commentary from  Catherine:  

The discussion section in the article states” Emerging evidence suggests that consistent oral feeding assessments may improve the preterm infant’s progression from gavage to full oral feeding and reduce the LOS. However, there is a lack of psychometrically tested feeding assessment tools. A comprehensive feeding assessment method that is psychometrically validated is needed to facilitate feeding progression for preterm infants.”

The Early Feeding Skills Assessment Tool developed by Thoyre , Shaker and Pridham is such a tool.

See: Thoyre, S. M., Pados, B. F., Shaker, C. S., Fuller, K., & Park, J. (2018). Psychometric Properties of the Early Feeding Skills Assessment Tool. Advances in Neonatal Care, 18(5), E13-E23.  See information on this publication in my June 2018 posts here on my website


Research Corner: Pediatric Feeding Disorder Consensus Statement

Check out the consensus paper in the January issue of the Journal of Pediatric Gastroenterology and Nutrition!   Click on the link below.

Facilitated by Feeding Matters and written by an international panel of 18 pediatric feeding experts, “Pediatric Feeding Disorder — Consensus Definition and Conceptual Framework” defines pediatric feeding disorder (PFD) as impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction.

By incorporating associated functional limitations, the proposed diagnostic criteria for PFD should enable the healthcare community to better characterize the needs of this diverse population of patients; facilitate collaborative care among the relevant disciplines; and promote the use of common, precise, terminology necessary to advance clinical practice, research, and health-care policy.

Problem-Solving: VFSS with former 24 weeker and thickening feedings


I have a question re: thickening formula in NICU. We don’t do vfss until >40 wks and no other compensations improve bedside feed.

We have a GA 24.6 wks; now 46.3 wks. Failed RA trial yesterday after 5 days of NPO/gavage only after a VFSS that documented laryngeal penetration and aspiration with slow flow in sidelying and upright with thin and nectar thick consistencies, so now NC 1/8L at 100%. Previously was bradying1-2x in a feed, so finally approved for the vfss…and while NPO limited to one Brady or desat a day. Vfss looked best with no penetration or aspiration with honey thick/IDDSI moderately thick. Would you agree with thickening of this infant to work towards safe feeds to go home with NCO2?


What is the etiology for the aspiration events? To problem-solve, one must understand the physiology that underlies the bolus mis-direction you observed during the VFSS.

Is possibly GER/EER a part of the differential, as some events when not with PO feeding? Wonder about the effect of EER on laryngeal/tracheal sensation. Guessing that as a 24 weeker CLD may be a factor so both EER and poor swallow -breathe interface are key considerations.

Thickening is, as you know,  a last resort when other interventions are not establishing a safe swallow. Honey thick is rarely being used, both in my experience and as I ask other therapists form across the US and other countries, when I teach my seminars. Honey thick is worrisome in that if the infant requires something so thick to establish a safe swallow “in the moment”, he could during the course of a feeding have a change in position, a change in state, a change in bolus size, a change in sucking strength, a change in breathing pattern) that could easily result in airway invasion. Further, aspiration of honey thick in the developing lung of a former preterm with CLD can create undue pulmonary issues for which the risk-benefit ratio may be quite precarious.

Asking this infant to PO feed and go home a full Po feeder may in the longterm not be a good plan for him, his neuroprotection, his joy in eating and his pulmonary health. Based on what I know about him, which is limited (? other complex co-morbidities than respiratory?), I’d advocate for a GTube and offer readiness interventions (including cautious therapeutic pacifier dips)  to maintain his oral-sensory-motor system for safe return to PO feeing when co-morbidities permit. Often these are infants who, after 1-2 months post discharge, come for a repeat study, and  have established improved respiratory function that allows for the beginning of some safe PO feeding.

I hope this is helpful.

Problem-Solving: Benefits of sidelying for infants and maintaining readiness for safe return to PO feeding


I have completed two VFSSs for infants (1-2 months corrected age) in elevated side lying position who then went on to have FEES completed at a larger children’s hospital. The FEES were completed in upright position. The VFSSs I completed demonstrated functional physiology and no penetration/aspiration; however, the  FEES reports I received documented aspiration and recommended NPO x 3 months. 

 My concerns are the FEES are being completed in a position that the infants aren’t typically being fed in (the literature searches I’ve completed haven’t shown that upright is better).  Parents have also reported to me after the fact that the infants were crying throughout the completion of the FEES.  Lastly, I do have questions about the length of NPO recommendation (e.g. not building on oral feeding skills/experiences for three months and then expecting infants to learn them after the time frame when feeding is driven by reflexes).  As you can imagine, having conflicting results has been tricky to navigate. 

I am interested in your thoughts on an upright feeding position versus side lying feeding position during  instrumental assessment (for Infants under 3-4 months of age).  Any advice you would be willing to share regarding the above scenario would be greatly appreciated as well!


Clinically I have consistently found that sidelying is more protective for swallowing and breathing, improves bolus control, and airway protection d/t muscular and gravitational impacts.

This is the most recent published paper/study by colleagues of mine:  Park, J., Pados, B. F., & Thoyre, S. M. (2018). Systematic Review: What Is the Evidence for the Side-Lying Position for Feeding Preterm Infants?. Advances in Neonatal Care, 18(4), 285-294.

FEES is clearly a valuable tool in swallowing diagnostics. Crying during FEES could, however, possibly  adversely affect the swallow-breathe interface, and therefore potentially contribute to an artifact that could alter physiology and lead to inadvertent airway compromise.

When an infant cannot PO feed d/t impaired physiology, we must still maintain the oral-sensory-motor system for future PO feeding. This includes non-nutritive oral-sensory-motor experiences which build components of oral-sensory-motor control combined with those components of motor control that underlie feeding function. Maintaining readiness often includes: offering tiny droplets of EBM preferably, or formula, on a pacifier or on the infant’s hands, or a trace dip of puree on a spoon. These offerings of create sensory load for purposeful swallows that stimulate fast twitch fibers.

This may of course carry some inherent risk, so one must carefully balance the risk for each infant with the benefits for long-term motor learning. Each infant must be considered in the context of his co-morbidities, developmental trajectory and day to day medical stability.

This cannot be approached as a cookbook but rather requires critical reflective thinking and clinical problem-solving to balance protection with learning. These experiences should be done after good oral cares, after postural stability is provided, and when the infant is at his best in terms of RR/WOB, state, postural organization, GI function etc.

The goal is to avoid loss of the multi-system integrated underpinnings for swallow function, avoid onset of disuse atrophy in a developing mechanism, and keep the emerging systems ready for future function.

I hope this is helpful

Problem-Solving: Pacifiers in the NICU and Aversions


I’m wondering if you have any insight into this. Despite developmental care and a good general awareness of feeding issues that may come down the road, we’ve had a group of chronic babies (<28 weeks at birth, long respiratory course- still on HFNC at 38+ weeks) that go from loving their pacifiers to gagging on them. Of course, it’s not surprising that these chronic, sick babies with arduous courses don’t want their pacifiers (or anything for that matter) in/near their mouths. Is there anything to do earlier in the course to prevent this? Besides developmental care/kangaroo care/making oral experiences as positive as possible/stopping with gagging. Some nurses are asking if we should avoid pacifiers earlier on in the course? Start therapy earlier? I don’t typically intervene in these kids earlier besides education for staff on developmental/kangaroo care (but do see them once stable respiratory wise and we’re thinking about nipple feeding to help guide readiness/nipple selection). Any thoughts? My gut is that we just to be extra vigilant about making sure the baby is ready/looking for/accepting the pacifier and tolerating it all along, encouraging skin to skin vs. actual interventions, but would love your input. Thanks as always for your expertise with these little ones!



You are such a critical thinker. They are so lucky to have you! It’s not the pacifier but rather most likely how the nurses may be inadvertently “giving it” to the infant.

I encourage infant-guided offering of the pacifier when the infant is able from a respiratory and GI perspective to accept it.

That means we need to use the infant’s communication to thoughtfully guide us.

Infant-guided neuroprotective offering of a pacifier means using the infant’s rooting response (by gently moving the pacifier across the infant’s lips) and then honoring the infant’s response. If WOB and/or RR is increased, the infant may not open his mouth and is saying “Not right now. I need to breathe; please wait and ask me again in a little while.”   Too often, caregivers mistake the infant’s not opening his mouth as an indication to just “place the pacifier” or “put the pacifier in”. But it is typically not lack of skill why he doesn’t take the pacifier, but rather he is purposefully not rooting to say, “not right now”. It is an adaptive/compensatory behavior whose meaning may be misinterpreted or misunderstood by some caregivers, especially those who are task -oriented versus infant-guided. GI discomfort may lead to the same response from the infant. Imagine being “asked/expected/”forced” to suck on a pacifier when don’t feel good in your GI system. The infant will remember how he felt. Good intentions to give a pacifier can inadvertently create negative experience.

When caregivers bypass this communication, motor mapping in the brain for the root-to-latch sequence will be altered and maladaptive behaviors can result.

Gagging, grimacing, pushing the pacifier out are all overt refusal behaviors. They look very different then “engagement” behaviors of rooting and focused attention. It really isn’t rocket science.

Perhaps even more worrisome is the stress created by being asked/expected/”forced” to do something that does not feel good right then.

The stress that results, like all NICU stress, has the potential to increase cortisol, change via the amygdala along the HP-axis, and change the architecture of the brain.

This is the pathway to learned refusal behaviors and learning to “hate” the pacifier.

The infant’s communication matters, as does every early experience using his mouth. Neuroprotection can be supported via an infant-guided approach to feeding readiness as well as feeding.



Shaker, C. S. (2018). ‘Mom, You Got This’: Feeding is communication. When we help NICU caregivers interpret what their preemie is telling them during feeding, we support the parent-infant relationship. The ASHA Leader, 23(10), 54-60.

Shaker, C. S. (2017, April). Infant-guided, co-regulated feeding in the neonatal intensive care unit. Part I: Theoretical underpinnings for neuroprotection and safety. In Seminars in speech and language (Vol. 38, No. 02, pp. 096-105). Thieme Medical Publishers.

Shaker, C. S. (2017, April). Infant-guided, co-regulated feeding in the neonatal intensive care unit. Part II: Interventions to promote neuroprotection and safety. In Seminars in speech and language (Vol. 38, No. 02, pp. 106-115). Thieme Medical Publishers.

Shaker, C. (2013). Reading the Feeding: The amount of milk a preemie drinks largely determines readiness for discharge from the neonatal intensive care unit. But just because an infant feeds well today doesn’t mean it will last. In the long term, fostering a child’s consistent, positive response to feeding may be more important. The ASHA Leader, 18(2), 42-47.

I hope this is helpful.


Problem-Solving: Enzymes in EBM that affect thickening


I am currently working in a Level 3 NICU and needing to thicken a baby’s formula to nectar. Baby was previously on fortified breastmilk, but I remember you saying at your course that breastmilk and oatmeal don’t bond. The neonatologist would like evidence. Do you have any suggestions where I can find this info?


It’s likely the Amylase (see below) — while its function when there is purely EBM from the breast is perfect, when additives for thickening are introduced in the EBM, it inhibits binding with oatmeal or rice cereal with the EBM. The oats and the EBM stay separated and therefore the EBM is not thickened.

See Enzymes Found in Breast Milk

There are many different enzymes found in breastmilk. These enzymes play an important role in the health and development of a newborn child. The enzymes in breast milk serve a variety of functions, some of which we do not even know yet. Some enzymes are necessary for the function of the breasts and the production of breast milk, some enzymes help a baby with digestion, and some are essential for a child’s development. Here are the most important enzymes found in breast milk.


Amylase is the main polysaccharide-digesting enzyme. It digests starch. Since babies are born with only a small amount of amylase, they can get this essential digestive enzyme through breast milk.


Newborns can fully digest and use the fat in breast milk because of lipase. Lipase breaks down milk fat and separates it into free fatty acids and glycerol. Newborns get energy from free fatty acids, and lipase makes those free fatty acids available before digestion occurs in the intestines.

Lipase is also responsible for the soapy, metallic smell that refrigerated or previously frozen and thawed breastmilk sometimes has. The cold temperatures and freezing and thawing of breast milk high in lipase can cause the fat in the milk to break down quickly leaving an unpleasant odor. It may not smell good, but the nutritional value is still good.


Protease speeds up the breakdown of proteins. There are high levels of protease in breast milk. It is believed that this enzyme is important for digestion especially during the period right after birth.


Lactoferrin is an iron-binding protein. It helps a baby absorb iron. Also, along with white cells and antibodies, lactoferrin kills bacteria. Lactoferrin stops E. coli from attaching to cells and helps to prevent infant diarrhea. Lactoferrin also prevents the growth of Candida albicans, a fungus. Lactoferrin levels are very high in preterm breast milk and the levels go down as lactation continues.


Lysozyme protects an infant against bacteria such as E. coli and Salmonella. The levels of lysozyme in the breastmilk rise especially around the time babies begin eating solid foods. The increase in lysozyme helps to protect children from germs that can cause illness and diarrhea.

I hope this is helpful.

Problem-Solving: Offering Tastes on NCPAP

Question: I am a Registered Nurse in a regional NICU where we take care of level 2, 3 and 4 infants. I am also co-chair of our dysphagia committee. We are currently doing a swallowing therapy-Therapeutic tastings. The current protocol allows therapeutic tastings to be done with our premature infants > 32 weeks adjusted gestational age that are on respiratory support as high as nasal cpap of 5 cm H2O. These tastings involve small volumes (0.05-0.1ml) of the infants current feeding administered to an infant using a syringe and adapter while infant is sucking on a pacifier, pumped breast or finger. The therapeutic tastings can be ordered to be administered 0.05-0.1 ml every 30 seconds up to a total of 2 ml TID by SLP, nursing staff or parent. Our medical team recently asked the dysphagia committee if it would be safe to do therapeutic tastings on infants that are on respiratory support higher than nasal cpap of 5 cm H2O (not including intubated infants). Is there any research supporting or disputing doing swallowing therapy such as our therapeutic tastings with an infant on respiratory support > nasal cpap of 5 cm H2O?


This question is not answered currently in the literature,  so,  as you have alluded to, caution and critical reflective thinking are essential.

Of course current level of respiratory support required is only one piece of the equation, as GA and other co-existing co-morbidities, WOB, respiratory history (arduous versus non-arduous course) are some key considerations that will affect risk to invade the airway, create undue stress that may adversely affect neuroprotection, and potentially then lead to maladaptive behaviors and aversions.

Take a look at Louisa Ferrara’s paper ( Bidiwala, A. A., Ferrara, L., Islam, S., Pirzada, M., Barlev, D., Sher, I., & Hanna, N. (2016). NEWS FROM THE NICU AND PICU: Effect Of Nasal Continuous Positive Airway Pressure (ncpap) On The Pharyngeal Swallow In Neonates. American Journal of Respiratory and Critical Care Medicine, 193, 1.

Results suggested that the driving force/flow under CPAP appeared to predispose infants to aspiration under fluoroscopy. I wonder if true pacifier dips — via droplet of EBM on pacifier tip— versus using a syringe where bolus size or speed of bolus delivery cannot be as readily controlled — would be a better option. That is what I prefer when the infant appears ready from multiple perspectives to initiate tiny tastes. It offers cautious opportunities for purposeful swallows but with a greater safety margin.

Due to the fragile nature of a premie requiring CPAP, I would have parents not deliver tastes but rather have parents learn along with the SLP or RN —how to recognize respiratory stress cues at baseline and with tastes, state modulation baseline and changes, swallowing behaviors (both audible and visible), postural/sensory-motor baseline and changes, signs of disengagement both subtle and more overt ——while the SLP or RN offers  the tastes and uses anticipatory guidance to explain what infant is communicating.    The complexity of what we are asking the infant to do clearly requires “in the moment” immediate infant-guided responses from the caregiver to optimize safety.  It is worrisome to expect parents to recruit the level of clinical reasoning required in these uncharted waters, as it is with the first PO feeding.  I find parents typically benefit from, and appreciate, learning along with the caregiver to build understanding of the multiple “avenues” of preterm infant communication during tastes as well as future PO experiences.  See Shaker, C. S. (2018). ‘Mom, You Got This’: Feeding is communication. When we help NICU caregivers interpret what their preemie is telling them during feeding, we support the parent-infant relationship. The ASHA Leader, 23(10), 54-60.

Offerings that are arbitrarily every 30 seconds perhaps may not take into account the infant’s ability or desire to continue. Alternatively, infant-guided offerings would best utilize infant communication from moment to moment to determine when an infant may be ready for another tiny taste.

I hope this is helpful.

Research Corner: Aspiration and Dysphagia in the Neonatal Patient

Aspiration and Dysphagia in the Neonatal Patient

Nikhila Raol, Thomas Schrepfer, Christopher Hartnick,

Clinics in Perinatology 45 (2018) 645–660



_ Management of neonatal dysphagia and aspiration should involve a multidisciplinary  effort, including neonatologists, otolaryngologists, pulmonologists, gastroenterologists, and speech-language pathologists.

_ Flexible fiberoptic laryngoscopy and a formal swallow evaluation in conjunction with the speech pathologist should be undertaken in any neonatal patient with dysphagia.

_ Babies born before 34 weeks may have dysphagia owing to a developmental delay.

_ Although the otolaryngologist may recommend acid suppression in patients with laryngomalacia, there is a lack of evidence to support use of acid suppression medications in suspected extraesophageal reflux disease.

_ Addressing anatomic/structural causes of aspiration are indicated when present; however, the vast majority are nonanatomic.




Research Corner: Silent aspiration — Who is at risk?

Velayutham, P., Irace, A. L., Kawai, K., Dodrill, P., Perez, J., Londahl, M., … & Rahbar, R. (2017). Silent aspiration: Who is at risk?. The Laryngoscope.

Among 1,286 patients who underwent MBS, 440 (34%) demonstrated aspiration. Within the aspiration group, 393 (89%) specifically demonstrated silent aspiration. Thin fluids were silently aspirated in 81% of these patients. Of children aged <6 months, 41% were found to aspirate and, of those, 95% silently aspirated. Median age at which patients demonstrated silent aspiration was 1.1 years. Silent aspiration was documented in 41% of patients with laryngeal cleft, 41% of patients with laryngomalacia, and 54% of patients with unilateral vocal fold paralysis. Laryngeal cleft, laryngomalacia, unilateral vocal fold paralysis, developmental delay, epilepsy/seizures, syndrome, and congenital heart disease were all associated with silent aspiration.

Their conclusions: Silent aspiration may be associated with several underlying conditions and is more common than previously described. Caregivers and clinicians should be aware that the absence of cough does not eliminate the possibility of aspiration. Modified barium swallow studies can reveal silent aspiration, which is difficult to detect on clinical feeding evaluation. Modified barium swallow findings can guide feeding therapy and the overall management of aspiration.

Read more….


Research Corner: Quality Improvement Initiatives Related to Cue-Based Feeding in Preterm Infants

Fry, T. J., Marfurt, S., & Wengier, S. (2018). Systematic Review of Quality Improvement Initiatives Related to Cue-Based Feeding in Preterm Infants. Nursing for women’s health.

A nursing team at The Children’s Hospital, OU Medicine, in Oklahoma City, OK examined and synthesized the outcomes of quality improvement (QI) initiatives related to cue-based feeding of preterm infants to facilitate implementation of findings to improve nursing practice.

Their review yielded seven studies related to cue-based feeding of preterm infants. Five studies included multidisciplinary stakeholder teams to assess their respective NICU environments and facilitate project completion. In two studies, feeding “champions” were designated as facilitators. In one study, researchers used a Plan–Do–Study–Act approach and emphasized process over outcome. In six studies, researchers measured hospital length of stay, which decreased in five intervention groups. In three studies, researchers measured infant weight gain, which increased in two intervention groups. In two studies, researchers monitored weight gain velocity, and in five studies, researchers reported earlier attainment of full oral feedings.

They concluded: Weight gain, time to full oral feedings, and hospital length of stay may be improved with the use of cue-based feeding. QI initiatives are a practical means to bring best evidence and multidisciplinary collaboration to the NICU.



Problem-Solving: Stridor in Newborn Requiring NICU Care

Problem-Solving: Stridor in Newborn Requiring NICU Care


We have an infant in our NICU who is presenting with stridor during inhalation and congested/loud breathing on what appears to be during exhalation. I have found with some infants demonstrating stridor they won’t have that congested sound to them, but others will. I asked one of our 38-year veteran nurses and she said she has found the same thing; some will have the congested/loud breathing sound and others won’t. We also do not have ENT’s in house so those that we find have stridor are RARELY sent out for it and we never get to see a report if an infant is seen in out-patient what the findings are. I feel my area of expertise is lacking in this area and would love some more guidance and education on the topic. My question is: Is this typical and if it is what is the reason for the different sound?


Sounds like you are describing inspiratory stridor. Can have varying etiologies, such as EER/LPR, laryngomalacia. Generally reflects a level of obstruction of the upper airway. The worry is that, with dynamic sucking, swallowing and breathing, it is not uncommon for the etiology/alterations related to the stridor to increase risk for airway invasion during PO feeding. With this clinical presentation, many physicians do not consult ENT, unfortunately, and assume its ok to just wait it out without knowing what’s causing the stridor. They perhaps due not understand the possible functional and safety implications.

In my experience, a clinical swallowing evaluation followed by an ENT consult/flexible scope at bedside can guide us to etiology, reinforce the need for a videoswallow study to objectify impact on physiology and likely interventions. The ENT may see reddened larynx or cords, altered airway structures that are known to adversely affect swallowing physiology.

Many infants with stridor mis-direct the bolus from below or above in my experience. The co-occurring congestion suggests either saliva/refluxate in the hypopharynx and/or laryngeal inlet (may be related to EER) and/or saliva (may be also related to EER and or poor swallowing), if congestion heard at rest. If congestion with PO, suggests potentially a mis-directed toward/above/in the airway. May be a combination of both.

Without hearing the infant, I am at a loss but loud breathing on exhalation suggests perhaps prolonged exhalation which may he be using to try to re-open the collapsing airway and/or to open the alveoli and add PEEP if there’s indeed some airway obstruction, or his trying to clear the congested material off the vocal cords or out of the supraglottic space perhaps. Just hypothesizing.

Other co-morbidities if present need to be correlated, though this may be an “isolated” altered airway problem. I use the quotes around “isolated” as it really is never truly isolated since it is part of a dynamic system (the swallow).  Could also be an additional component of lower airway alteration (tracheal/bronchial). ENT sounds essential to elucidate the integrity of the airway to assist you in your differential.

Clinical problem-solving is my passion. That’s why I developed my 2-day Advanced Pediatric Dysphagia seminar which will be offered again in 2019!

New Shaker Publication – “You Got This Mom” – in the American Speech-Language Hearing Association (ASHA) Leader

New Shaker Publication – “You Got This Mom” – in the American Speech-Language Hearing Association (ASHA) Leader

Feeding is Communication. When we help NICU caregivers  interpret what their preemie is telling them during feeding, we support the parent-infant relationship.

Excerpt: ” What builds confidence is shifting the focus to feeding quality and their relationship with their infant. We get there by helping parents conceptualize feeding as a “conversation” with their infant. Our role as feeding specialists in the neonatal intensive care unit (NICU) is to guide parents to develop this “co-regulation” with their infant—this line of communication that drives feeding, and, ultimately, the parent-infant relationship itself. With our ongoing support, parents can begin to see their relationship with their infant as the foundation for feeding. Intake is then viewed as the byproduct of a quality feeding interaction, not the feeding’s only goal. And so, the parent-infant-relationship begins, through infant-guided feeding.”

Read more ………

Follow the link below to the full article on the ASHA Website.