Problem-Solving: New infant referral but limited experience

Problem Solving Techniques in Artificial Intelligence (AI) -


I did infant feeding many, many years ago. Just got a referral for a 4-month-old, NG tube, congenital heart disease, some bottle feeding. 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 response:

It reflects your thoughtfulness that you reached out, as I suspect your instincts are telling you to think this through. Because our cardiac infants are some of our most fragile feeders. Given that her history and co-morbidities are likely complex, she will require some high-level problem-solving to keep her safe and to sort out all the pieces. Even after many years of complex infant feeding, I still have to pause and really think through these complex little ones. She is likely at high risk to invade her airway. Balancing the VFSS results, and her arduous course with family before you can be quite challenging for all of us. Before you accept referrals for infants with feeding problems, take the time to fully understand the underpinnings specific to congenital heart disease and its impacts on feeding and swallowing (and WOB and state regulation and postural control and neurodevelopment), as they will all need to be a part of your differential and plan. The infant-guided interventions for safe swallowing in infants, s/s that suggest a different plan, won’t be available to you right now. So, perhaps think about first building your guided/mentored experience with feeding/swallowing with more complex toddlers, then older more stable infants in EI and then increasing the complexity to younger and more complex infants. Taking courses under the gun isn’t the path to the critical thinking that is required with each population we serve, especially one so fragile. It would be no different if tomorrow I were asked to work in adult ICU at the very large medical center in which I 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 clearly noted by an attorney or an expert witness from my limited preparation for that population. The risks all around would not be a good situation. If this (infant feeding/swallowing) is a direction you are passionate about, make a “long-term” (not “stop-gap”) plan (perhaps over 6 months rather intense and then an ongoing commitment) to read, read, read the research, take some highly recommended courses about infant feeding, find a mentor whom you can observe and learn along with. The things in life that we become successful at are rarely if ever easily attained. Allow yourself the time and support required.

Shaker Seminars 2023 Schedule: Coming Soon!

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Many of you have asked about my 2023 Seminar Schedule. It will be out very soon. You are welcome to join me for:

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

When I created my seminars, and as I update them, I always think ‘What do I wish I had known, both research and clinical information, to practice in peds dysphagia when I started out? What is essential to work toward practicing at the top of our professions?’  Each seminar is filled with everything I want to pass along. As I learn from colleagues and attendees at my courses, I weave that in as well.

I will always offer you a welcoming environment that fosters interaction and learning along with each other.

Sign up for my blog to receive a notification when my 2023 schedule posts and registration is open. I look forward to learning along with you in 2023!


Problem-Solving with Catherine: 3-month-old with TEF and Vocal Cord Paralysis


QUESTION: I am currently working with a 3 month She had a TEF repair and has a paralyzed left vocal cord. Her most recent MBSS on 9/15/22 indicated delayed initiation, reduced tongue base retraction, reduced laryngeal sensation and primary concern being uncoordinated SSB. She has a PEG tube, and they recommended slightly thickened breast milk via Dr. Brown’s Level 1 and PO intake to be limited to 2 practice feeds daily up to 60 mls. Practice feeds have been going really well, per data her Mom is taking at home, she is slowly increasing volume, reducing the time it takes to consume practice feeds and feeds have been pleasurable with interventions (elevated side lying on right side, external pacing ever 4-5 sucks and thickening breastmilk). Mom also indicates she seems very fussy when the bottle is removed, as she would like to keep eating. Should I ask the medical team about offering oral feeds for a certain length of time (15 minutes) at each tube feeding time if she is showing readiness and as long as she maintains homeostasis and whatever she doesn’t take orally, provide through the tube. She did aspirate thin breast milk her last two swallow studies.

CATHERINE’S ANSWER: Sounds very risky for airway invasion given impaired swallowing physiology in the setting of her co-morbidities. Do we know that in the VFSS thickened EBM was objectified as to its effects? EBM is super thin so when we thicken it slightly and use a Level 1 Dr Brown’s, it seems like that might be too fast flow to minimize air swallowing and bolus misdirection, in the setting of a L VCP and her pathophysiology. What thickener was objectified during the study? Did the radiologist look at upper esophageal function with thickened EBM during the study? How did the swallowing physiology look with the thickening – safe? precarious but no witnessed airway invasion? penetration without aspiration? Thickening may create increased challenges for resistance to bolus flow through the anastomotic site. When as the last UGI/esophagram to objectify whether there is a narrowing? When as she last dilated? Our surgeons typically dilate about every two weeks through the first two years of life. based on what I understand at this point, I would recommend not PO feed until these pieces are sorted out but continue to offer pacifier dips for purposeful swallows to keep her oral-sensory-motor system primed for return to PO.

Lifelong Learners Join Catherine in Houston

My final seminars for 2022 held at Texas Childrens Hospital in Houston brought together SLPs and OTs from across the US and Canada, including Stephanie, pictured with me above. From new graduates to seasoned therapists, we shared complex patients, and problem-solved the “bigger picture” as our framework for interventions. Such a great opportunity to learn along with each other, and to have the time to grow our critical thinking skills that underpin swallowing and feeding practice, from infants through adolescents. Our conversations and discussions helped each of us realize that the challenges we each face are not unique, and we are all in this together. I can’t wait to continue the conversation in 2023!

State-of-the-Art NICU Practice: Catherine Shaker and Suzanne Thoyre

Just returned from Houston after presenting with my colleague, Dr. Suzanne Thoyre, a gifted and remarkable researcher and neonatal nurse. The attendees came from across the US to share our common passion for infant-guided co-regulated feeding in the NICU and after discharge.

Our Early Feeding Skills Assessment Tool was the framework for advancing cue-based feeding, problem-solving challenges in the NICU and beyond, getting everyone “on the same page” through a common language, and supporting parents in building a relationship with their infant through feeding. We all left renewed and empowered to be the change … and with a solid path forward.

Catherine Shaker Seminars: Reinforce Your Intellectual Curiosity !

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

Intellectual curiosity is known as one of the hallmarks of a lifelong learner.  The intellectually curious person has a deep and persistent desire to know. She asks and seeks answers to the “why” questions. And she doesn’t stop asking at a surface level, but instead asks probing questions in order to peel back layers of explanation to take a deep dive …..and that changes everything.

Join me in 2023 for advanced clinical learning opportunities! Sign up for my blog on any page of the website to receive a notification of the 2023 schedule when it launches.

Each of my state-of-the-art seminars is infused with the latest research and problem-solving, enhanced by my 45 years of progressive clinical experience.

I promise you a welcoming environment that fosters interaction and learning along with each other. Will change your practice. See you in 2023!




Catherine Shaker Seminars: “Formula One” Style in Austin!

     The flagman waves the chequered flag as Red Bull's Dutch driver Max Verstappen crosses the finish of the Austrian Formula One Grand Prix in...

Formula One, part of the US Grand Prix, came to Austin in October and so did I!

The Feeding and Swallowing Team at Dell Children’s were amazing 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. In the Cue Based seminar, Dr Thoyre and I guided the group in higher level conversations about complex feeding challenges in the NICU and after discharge, watching and scoring videos of neonates feeding and problem-solving next steps. In the Pediatric Swallow Studies seminar, we discussed unique components of the swallow pathway across the pediatric age span, and then peeling apart the pathophysiology and its implications.  In the Advanced Dysphagia seminar, we looked at critical thinking for decision-making, problem-solving and interventions for our neonatal through school aged patients.  It was also a great opportunity to share ways of navigating the practice challenges that each of us faces on a daily basis. It reminded us that we are not alone. One attendee commented: “I feel rejuvenated and validated in my practice, and our conversations reinforced my values as a clinician. ” We all walked away feeling renewed.

Problem-Solving with Catherine: 5-year-old with Athetoid Cerebral Palsy

QUESTION: I work in an outpatient pediatric rehab setting and recently saw a 5-year-old boy with athetoid cerebral palsy (CP) and frequent tonic reflex. His suck-swallow-breathing coordination is poor (multiple suckles followed by multiple swallows, then gasp for air), wheezes heavily, and often he has difficulty clearing his phlegm, has poor lingual range/control, uses phasic bite when foods presented. Parents have not had a VFSS done before.
 His parents “force” feed him with bread, which often stays in his tongue/sides of roof of his mouth. With thin liquids fed with a bottle, anterior spillage occurred (he can’t seal with his lips). Except for liquids (bottle-fed) he is often in distress during mealtimes. My other colleagues reported that he was also fed with rice. I tried educating parents and demonstrated to them how he handles puree and thickened milk much better, but they were against the recommendation, and stated that what I interpreted as distress (e.g., tensing/tightening his lips, head turn, increased tonic reflex, protesting (tensed vocalization) during mealtimes, and crying), is just him trying to eat. They claimed that whenever he attempts to do anything, that’s him tensing up, so they continued to ignore my advice and called my observation a ‘cookie cutter’ statement from textbook, which doesn’t apply to their boy. They said the child has never choked with bread all these years, why stopped him now?
I’ve observed him smiling and relaxed when he’s in comfort, and in my experience, if a diet is too difficult for a non-verbal child to manage, these are signs of distress.  He is quite intentional with his communication (smiles and looks at you if he wants an action/object), it’s hard for me to understand where his parents’ perspective.
I wanted to run by you to see if I might have misinterpreted this child’s body cues. What other strategies can you use to convince parents?
I referred them for a VFSS, so they can at least ‘view’ what’s happening when their child’s eating.

Our children with athetoid cerebral palsy typically present with complex swallowing/feeding challenges similar to those you describe and are very often fragile feeders. Their lack of postural stability and excessive postural mobility provide a poor base of support for the head/neck and oral motor/laryngeal/pharyngeal control along the entire swallow pathway. What you are seeing is indeed worrisome related to the swallow-breathe interface, likely caused by “problems down the line” as part of an overall unstable hyolaryngeal and esophageal complex. This affects not only chewing but the foundations for even swallowing saliva with integrity, and, as such, can often create the perfect storm for airway invasion, both silent and symptomatic. Safety of his liquid swallows is very likely adversely affected as well, especially given that the tongue plays a key role in liquid control and transport. The anterior spillage you describe has many aberrant components beyond lip control that likely do impact swallowing integrity and safety, as the entire system must work together in synergy. He likely lacks the stability and control for any solids, both purees (that may lead to stasis after the swallow) and the “pieces” that likely disperse and can be “underperceived” by a sensory system that is also likely adversely affected, given the overall neuromotor picture. The overt distress behaviors you have witnessed are a typical constellation with this diagnosis and its functional implications. His behaviors to some extent reflect what we call adaptive behavior, i.e., refusals and struggle that likely reflect his fear, learned discomfort and indeed possible airway invasion, that then lead to maladaptive feeding/swallowing behaviors. For families, this long-observed feeding behavior has perhaps become what they see as “just him” when he eats or drinks… much like an NICU nurse who at times may view the excessive WOB and tachypnea we witness at feedings with an infant with CLD as “just who the baby is”. But we know that, who that baby or child “is” is indeed worrisome. It reflects risk and is not then “ok”, when it comes to airway protection and indeed neuroprotection, for both children with complex co-morbidities, and for infants.

I suspect this little guy has learned to “struggle through” his parents’ well–intentioned feeding approach, sadly. They don’t understand his feeding behavior and its actual significance, which is his communication to them. And they are likely still grieving the loss of the normal child their hearts expected, so your thoughtful and likely quite accurate assessment of risk is something they may not want to hear, which is understandable in many ways. Our hearts go out to them.

Trust your instincts. The VFSS will be important to help them see the “why” behind his struggles. They are fortunate to have you in his corner.

Problem-Solving with Catherine: Infant in NICU with HIE

Ohio HIE Lawyers | Infant Hypoxic Ischemic Encephalopathy

QUESTION: I have a little patient that experienced prolonged hypoxia at birth and has been diagnosed with HIE grade 3. This patient is currently on oxygen via Nasal cannula and there is retraction during breathing. Also, notable secretions on the lips and pooling in the oral cavity of these secretions. When I went to assess the suck with my gloved finger, even with oral stimulation, no suck was elicited. This patient is currently on NGT feeds. Would you recommend the use of a pacifier to help with the suck and if so, which pacifier is recommended (I’m not too sure which literature to consult on this so any suggestions are appreciated). The hospital I work at does offer the option for instrumental assessment, but they will only do a barium swallow (not even a modified), so I will suggest this and know the patient will likely be for a PEG long term, but any advice and suggestions would be great 🙂

As a side note, the hospital I work at is very under resourced and we don’t have access to great equipment or specialists like pulmonologists which does limit intervention options.



Sounds like this little one has complex neurological sequelae due to the HIE. The absent suck suggests there is also no active tongue movement for initiating or driving a swallow. I suspect her gag/pharyngeal responses are blunted as well. That affects ability to mobilize secretions/saliva posteriorly, to clear the pharynx and move the saliva away from the laryngeal inlet. This constellation of impairments is due to the overlapping function of the cranial nerves that support suck-swallow-breathe, which also “take a hit” as a group when there is hypoxia or ischemia in the newborn. I suspect infant also has diffuse postural hypotonia which provides a poor base of support for the hyolaryngeal musculature, blade and base of tongue, and muscles of respiration. High risk of ongoing silent aspiration of saliva/secretions due to motor and sensory impairments. Likely unable to generate a cough when needs to. Without a swallow response, we would not take infant for a swallow study as we would likely passively see barium invade her airway. Also we clinically see the behaviors s/o an absent swallow.

The history provided is quite helpful for us to problem solve. The clinical presentation as I understand it, in the setting of the infant’s history and co-morbidities, suggests a very poor prognosis for establishing even safe saliva swallows in the near future. I would recommend work up for a G-Tube and Nissan (as she is also at high risk to aspirate refluxate if there is EER, which is more likely given postural hypotonia). Continued intervention via providing postural stability, offering own hands to face/mouth, facilitating rooting response (which is also likely absent), providing deep pressure input to the biting surfaces, to the intrinsic tongue muscles and base of tongue muscles, f/b functional input with your gloved finger and then standard shaped pacifier to facilitate rhythmical responsive lingual movements. It’s a combination of oral-motor, oral-sensory and neurodevelopmental treatment to support motor learning. Intervention will be based on a thoughtful process and change will be slow, based on what we understand so far about the infant’s back story. The pieces we don’t know about birth history, intra-partum and post-partum infant response,  Apgars, how long intubated, progress with state modulation and progress to date neurologically, would all help refine our differential and, I suspect, likely make infant’s prognosis even more worrisome. We offer parents guarded optimism, in that the infant’s story is not written yet and some of our infants amaze us. Early intervention, including ST, PT and OT, and follow through by a supportive family will be key to optimizing progress.


Research Corner: Congenital Heart Disease and Vocal Fold Immotility

Congratulations to our pediatric colleague, Christine Rappazzo, for this wonderful addition to our evidence base related to the potential impact of the need for heart surgery on airway protection in our infant population. This, combined with the documented increased risk for R vocal fold motion impairment post ECMO in this population, helps us to advocate for our involvement in safe progression to PO for these vulnerable infants.

Citation: Narawane, A., Rappazzo, C., Hawney, J., Clason, H., Roddy, D. J., & Ongkasuwan, J. (2021). Vocal Fold Movement and Silent Aspiration After Congenital Heart Surgery. The Laryngoscope.


Infants who undergo congenital heart surgery are at risk of developing vocal fold motion impairment (VFMI) and swallowing difficulties. This study aims to describe the dysphagia in this population and explore the associations between surgical complexity and vocal fold mobility with dysphagia and airway protection.


This is a retrospective chart review of infants (age <12 months) who underwent congenital heart surgery between 7/2008 and 1/2018 and received a subsequent videofluoroscopic swallow study (VFSS). Demographic information, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of each surgery, vocal fold mobility status, and VFSS findings were collected and analyzed.


Three hundred and seventy-four patients were included in the study. Fifty-four percent of patients were male, 24% were premature, and the average age at the time of VFSS was 59 days. Sixty percent of patients had oral dysphagia and 64% of patients had pharyngeal dysphagia. Fifty-one percent of patients had laryngeal penetration and 45% had tracheal aspiration. Seventy-three percent of these aspirations were silent. There was no association between surgical complexity, as defined by the STAT category, and dysphagia or airway protection findings. Patients with VFMI after surgery were more likely to have silent aspiration (odds ratio = 1.94, P < .01), even when adjusting for other risk factors.


Infants who undergo congenital heart surgery are at high risk for VFMI and aspiration across all five STAT categories. This study demonstrates the high prevalence of silent aspiration in this population and the need for thorough postoperative swallow evaluation.

This will inform your pediatric practice whether in the inpatient or community pediatric setting.





Learning about Feeding/Swallowing: An International Pediatric Perspective

I was thrilled to welcome new SLP friends from Europe who traveled to Chicago to learn along with me! Florentine (left) from The Netherlands, and Heida (right) from Iceland.  Between them, they traveled over 7000 miles to be with me for 5 days. Despite our geographic distance, our infant and pediatric patents are so similar, as are the challenges we face each day. Their approaches and physician/institutional influences really are not all that different but their wisdom in thriving with different and less abundant resources were an eye opener for all of us. International perspectives on feeding and swallowing always round out conversations at my courses. It has been my pleasure over the years to welcome an ENT from Saudi Arabia, a pediatric dentist from Japan and in-the-trenches therapists from other far way places including Spain, Greece, the UK, South Africa, Australia, India, The United Arab Emirates, Ireland and Israel. Needless to say, my brain is on fire after the chance to share our passion for helping infants and children with feeding and swallowing problems. And it is great to have contacts for future problem-solving that literally span the globe! Safe travels to my new friends, Florentine and Heida!

Pediatric Swallowing/Feeding: “We are all in this together!”

I just returned from teaching in Chicago for 5 days at Advocate Aurora Healthcare.  What an amazing pediatric team they have…engaged, thoughtful and embracing both the evidence base and the value of problem-solving. We were joined by therapists from across the US and Europe for conversations about our shared challenges …complex infants and children who land on our doorsteps, navigating swallow studies with physician colleagues, implementing IDDSI, fostering cue-based feeding in a volume-driven culture, GI co-morbidities from FTT through  ARFID in kids, the latest information on aspiration in the pediatric population, risks for feeding on CPAP/HFNC, enduring impacts of neurologic sequalae, and integrating motor learning as the foundation for rehabilitating and habilitating the swallow from infants through adolescents, and so much more. We all came away with new ideas, new data, new perspectives and a resounding sense that we are all in this together as pediatric swallowing and feeding specialists! We can do this!

Problem-Solving: 30-month-old with Random Gagging and Altered Swallowing Physiology


Recently, I completed a MBSs on a 30-month-old child secondary to complaints of vomiting, gagging/choking at random. At age 24 months, child had tonsillectomy/adenoidectomy completed secondary to vomiting/gagging with the hopes this would correct child’s difficulties. MOC reports that this did help some however reports difficulties have not completely resolved. Per MOC, child had pacifier until age of 20 months. At time of MBSs child did consume pureed and thin liquids, they refuse all other bolus consistencies. Child noted to have a high palate arch and slightly narrowing in front of mouth. Delayed swallow to the level of the pyriform sinus was observed, suspect secondary to poor retraction and elevation of tongue to soft palate due to high arch. No penetration or aspiration noted. Appropriate ROM with tongue was observed during attempts at oral facial/motor examination. Per MOC, child is a picky eater, consumes 30oz of milk daily, will pocket food and spit it out and gag on water intermittently.

Based off of how this child presents, I would focus on lingual strengthening, age-appropriate mastication patterns and acceptance of age-appropriate foods. For a child of this age, what would your recommendations be for treatment/tasks to obtain these goals/exercises etc.? I am running into a roadblock per say. From my research and reading, I have found great ideas for older children or adults who follow verbal directives, however due to this child’s age, I am stuck!


Is the child otherwise normally developing? Is postural /sensory-motor control age-appropriate?  I am asking because sometimes this type of clinical presentation is part of a bigger sensory processing issue or part of a constellation of craniofacial alterations or alterations across developmental domains. That creates a different “bigger picture” from which to problem-solve.

Craniofacial malformations often co-occur with changes in the muscular network that supports those structures. The high arched (and sometimes “tented”) palate can co-occur as part of a genetic syndrome and can co-occur with mandibular hypoplasia. Mandibular hypoplasia alters lingual and supra/infrahyoid muscular ROM and their functional coordination.

Interestingly, I have seen across the age span that, with this clinical presentation you described, it is not uncommon to have co-occurring tethering of oral tissues. I suspect that, if there are TOTs, this may be because the formation of these structures and muscular attachments occurs around the same time in utero. Then their motor sequences are initially mapped in utero through swallowing of amniotic fluid. So, the underpinnings for a well-integrated oral-motor system are underway quite early. Maladaptive networks also start in utero and the foundations for function can then start off in infancy already altered and impact future function that “feeds forward”, as our PT colleagues call it, in motor learning. So, implications unfold overtime.

If there are tethered oral tissues, or related alterations, they can at times be more subtle. These alterations can create challenges for the emergence of motor plans along the swallow pathway, and for bolus control and manipulation. That may also provoke the air swallowing that can lead to the vomiting/emesis you report. We must of course recognize that tethered oral tissues are not always the explanation/etiology, but should be a part of your thoughtful differential, as it could explain the functional limitations you describe. As could altered oral-facial tone, an altered overriding postural network, and/or sensory integration problems, and other possibilities, depending on the unique “bigger picture” for this child. Thinking through that bigger picture will best guide targeted interventions.

A wonderful resource on the neurodevelopmental underpinnings for feeding development is included in Robyn Walsh and Lori Overland’s book on “Functional Assessment and remediation of Tethered Oral Tissues”. Even if TOTs are not part of this child’s etiology(ies), their tutorial included in their book is not just about TOTs but is a foundational must read on functional oral motor development. By two of our wonderful SLP colleagues.

The swallow study would likely reveal any alterations in base of tongue retraction and pressure generation that may be created if tethering were impacting this child’s swallow pathway. For some children, the oral phase appears most altered, but that of course can cause problems down the line such as gagging and “sudden” loss of control which mother describes, which may reflect challenges with coordination during the dynamic swallow (when the need for exquisite motor mapping is required).

The attached article by my colleague Laura Brooks that adds to our understanding of the potential implications of some of the potential alterations. Even though with your patient there was no witnessed airway invasion, there was an alteration in physiology that likely is connected somehow to the functional differences you are seeing. This may take some peeling apart layers of data through a second and third look. Or more. And it may take a while to sort out and trial the interventions that best meet your differential. And that’s ok. It’s complex but you have a good start.

Click here for Laura Brooks article

Practicing at the Top of Your Profession in Feeding/Swallowing

An SLP asked recently, “What resources, articles, courses, etc. did you find helpful when you were first learning infant feeding? I’m looking for something to give me what I really need.”

“My seminars” I told her, “are designed to do just that. When I created them, and as I update them, I always think ‘What do I wish I had known, both research and clinical information, to practice in peds dysphagia when I started out? What is essential to work toward practicing at the top of our professions?’  My NICU and Pediatric as well as Advanced seminars, my Peds/ Neonatal Video Swallow Studies and Cue Based seminars are filled with everything I want to pass along. As I learn from colleagues and attendees at my courses, I weave that in as well. Sometimes I almost run out of time!

I will always offer you a welcoming environment that fosters interaction and learning along with each other.

Click here to download Shaker 2022 On-Site Seminars Brochure

Click here to Register