I designed this course to fill that void that is out there—about the evidence-base and critical thinking for clinicians in the trenches — to support well-thought-out studies that look far beyond “aspiration” and “thickening”…
It’s not the radiographic image alone that contributes to an impression and plan of care. The course is designed to provide the latest evidence-base regarding evolution of/progressive changes (with age) in both structural relationships and physiology from birth through the age of about 6 (based on the data and research we have), when the swallow becomes adult-like in all respects for the typically developing child. This information helps to understand where to specifically map interventions—even for therapists that don’t conduct swallow studies. The focus of the course is not on looking for or finding “aspiration” but on objectifying swallowing physiology (or pathophysiology), considering how that physiology may impact airway protection and relative risk for airway invasion, and then critically considering, in the setting of that child’s unique history and co-morbidities, how to optimize safety —and objectifying potential interventions there in radiology, finally providing the thoughtful impressions that round out the picture of mealtime impact for the team. These underpinnings for critical thinking are key for any treating therapist, even if that therapist does not conduct swallow studies. Making sense of the dataset, if useful data is gathered, is not the sole domain, nor the sole responsibility of the therapist doing the study. Understanding physiology and its connection to function and intervention is essential for treating therapists too—That knowledge base makes us more effective problem-solvers and critical thinkers every step of the way. So much underpins what we do as swallowing/feeding specialists. Physiology, and the impact of pathophysiology, is at its heart.
Some feedback from previous attendees to my Pediatric Videofluoroscopic Swallow Studies seminar:
Even for someone like me who doesn’t do VFSS, I learned so much about the biomechanics of the pediatric swallow that now can inform my treatment. Leana, SLP
Catherine’s Swallow Studies course was the most detailed education I have had related to the dynamic interaction of the oral, pharyngeal and esophageal phases and how they play on one another. Her breadth of well-rounded knowledge and ability to easily relate it to practice is wonderful. She is so approachable which makes it a comfortable environment. Lisa, OTR
The information presented by Catherine in the VFSS course was so well researched. I feel confident that I can add all of this info to my clinical knowledge, and I know where to find more info (via the many citations)! Kari, SLP
As an outside provider (not in a hospital doing VFSS), this was great info on how I can communicate what I’m looking for and why I’m recommending a VFSS. The time watching videos of swallow studies helped my brain process the reports I read when I can’t be at the actual study in person. Minnie, SLP
Catherine had a great way of effectively presenting information through multiple modalities. The x-ray stills, videos of so many different etiologies and the case studies in radiology have tremendously increased my confidence with pediatric MBSS. Heather, SLP
This course gave a great perspective on how to effectively determine and describe a disruption in swallow physiology for parents, physicians and other professionals. I loved the video examples! Rachel, SLP
The swallow studies course is an excellent synthesis of the dynamic aspects of pediatric swallowing and an exquisite way to transition to VFSS. Monique, SLP
What a great course on pediatric swallow studies. Now I know to think physiology, not just aspiration and penetration!! Yeah! Samantha, SLP
I am surprised and enlightened by how much I have learned considering I have been doing pediatric VFSS’s for 15 years! Natasha, SLP
I am just starting my VFSS training, and this course will help tremendously! A wonderful opportunity to consider differentials for many different clinical presentations. Jennifer, SLP
Just returned from teaching in Long Beach, California for six days! What a beautiful part of the West Coast. Nearly 200 engaged and passionate rehab professionals (SLPs and OTs) joined me for this practice-changing event.
A memorable experience for all…
Here I am with some new colleagues I met there, celebrating each other, being lifelong learners, and the common thread…our passion for feeding and swallowing….and for the infants and children and families who trust their care to us!
Join me in San Antonio, TX (July), Fremont CA (September), Dallas or McKinney TX (October). I promise you a learning experience that you will always remember!
Click here for Catherine Shaker Seminars 2026 Brochure
Click here for Site/Location Info
Sharing a link to the webinar I presented on May 5, 2026, for Dr. Brown’s:
Complex Swallowing/Feeding in the NICU:
Where’s Your Magic Wand When You Need It?
Catherine Shaker
M.S./CCC-SLP, BCS-S, NDT/C
Click on this secure link to access the one hour webinar:
Overview
The journey to successful oral feedings for many preterm and sick infants and their families in the Neonatal Intensive Care Unit (NICU) can be arduous. This live interactive webinar is designed to capture the dynamic problem-solving process that underpins the infant’s journey to safe and successful feeding both in the NICU and beyond. There can be multiple roadblocks, such as sequelae from medical co-morbidities, well-intentioned actions that create risk, and worrisome clinical presentations that require a thorough differential, critical thinking, and consideration of risk-benefit at every juncture. Collaboration, especially with parents, and the entire care team is essential to truly support infant-guided feeding, and positive protective feeding experiences.
I hope you enjoy this learning opportunity~
Congratulations to our colleague, Jenny Reynolds SLP, for her recent publication on dysphagia in preterms – such a wonderful addition to our evidence-base. Thank you, Jenny!
Reynolds, J., Suterwala, M., Desai, S. et al. Incidence and factors associated with dysphagia in infants born very preterm or very low birth weight. J Perinatology (2026).
Abstract
Objective
To determine the incidence of dysphagia and define the associated co-morbidities in infants born very preterm (VP) or very low birth weight (VLBW).
Study design
This is a retrospective cohort study evaluating 158 VP or VLBW infants born over two years. Forty infants diagnosed with dysphagia confirmed by flexible endoscopic evaluation of swallowing were compared to 118 infants with no dysphagia.
Results
The incidence of dysphagia was 25%. After adjusting for gestational age and birth weight, dysphagia was associated with morbidities such as necrotizing enterocolitis, bronchopulmonary dysplasia, and intracranial hemorrhage. Regression analyses indicated that dysphagia was associated with higher central line days and longer hospital length of stay. Feeds were thickened in 38 infants (95%) before discharge and 3 infants (7.5%) needed gastrostomy tube.
Conclusion
Dysphagia is an important morbidity affecting a quarter of the infants born VP or VLBW. Significant associations with other major morbidities were noted.
McKinney TX October 19 – 22, 2026 
So excited for the hundreds of therapists (and a few MDs and nurses too!) already registered to learn along with me this year. What wonderful discussions we will have!
If you are thinking of joining us, make a plan to register soon ☑️
No matter your age, most of us have ideas of things we would love to do at some point. A bucket list is comprised of experiences or achievements that a person hopes to have (or accomplish) during their lifetime. It usually consists of things that someone hopes to do before it’s too late.
Join me for the last locations on my final tour this year…San Antonio TX, Fremont CA, McKinney TX ***Dallas location SOLD OUT***
As always, I promise you an exceptional learning opportunity to:
I hope our paths cross in this year!
Click here for Catherine Shaker Seminars 2026 Brochure
Click here for Site/Location Info
Hazkani, I., Valika, T., & Thompson, D. M. (2026). Congenital Laryngomalacia: Pathophysiology, Clinical Spectrum, and Holistic Management. Otolaryngologic Clinics of North America.
I hope that this just-published paper on congenital laryngomalacia informs your infant feeding practice and critical thinking like it did mine. It is from the amazing physicians at Lurie Children’s in Chicago. Reading the literature designed for our physician colleagues helps us speak from a perspective of knowledge when we advocate for the infants we care for.
Feeding difficulties are common in this population, and often include color change, inspiratory stridor, wheezing and recurrent respiratory infections. Depending on the setting of their co-morbidities, these infants are often worrisome for silent aspiration as a consequence of co-occurring anatomic and neuromuscular differences and inflammatory mechanisms. There is an interactive relationship between the infant’s dynamic airway obstruction, resulting changes in pressure gradients throughout the aerodigestive system, and altered respiratory regulation that combine to disrupt the swallow-breathe interface swallow-breathe interface. Resulting crying and physiologic stress provoke further risk for airway invasion. Multiple papers have reported a resulting high risk for aspiration, often silent, and chronic airway inflammation. The authors note that: “Given the high prevalence of silent aspiration, the threshold for ordering swallow studies should be low, and dysphagia assessment should be incorporated into routine evaluation.”
KEY POINTS quoted from the abstract
Congratulations to our NICU colleague Deborah Levine-Kotin for her recent publication regarding positive impacts of reusable bottles versus disposable in the NICU. So many takeaways that inform our NICU practice. From the wonderful benefits of partnering with nursing authors to look at and improve practice, to improved LOS with predictable feeding experiences , and improved LOS with reusable bottles… these are all outcomes many of us have noted clinically that now have data to support them.
Haynes, A., et al (2026). Impact of reusable bottle nipples compared to dis posable bottle nipples on infant feeding outcomes in the NICU. Pediatric Nursing, 52(1), 7-12, 51.
From the Abstract: Research has shown that variability of disposable bottle nipples impacts infant feeding experiences. Negative feeding experiences impact time to full feeds and length of stay (LOS). At the time of this study, utilization of reusable bottle nipples from the initiation of oral feeds had not been examined in relation to infant outcomes. This study examined the impact of reusable bottles on time to full feeds, LOS, and feeding stability when compared to disposable bottles among infants born 28 to 35 weeks. Chart reviews were completed on a pre-intervention group of 50 patients and post-intervention group of 50 patients. Data were collected through chart reviews of the primary outcomes: time to full feeds, LOS, and feeding stability score (FSS). The repeating measure of FSS was collected on 25 pre intervention and post-intervention charts. Secondary outcomes included hospital costs and sustainability measures. When adjusted for gestational age, LOS in the post-intervention group was 3.59 days shorter (p = -0.13) than infants in the pre intervention group. Nipple change alone was not an indicator of decreased FSS or decreased LOS. Rather, infants with any bottle brand change during their stay regardless of group went home 2.4 days later (p = -0.06). Change to reusable bottles saved 1130 pounds of plastic waste annually. Findings from this study support the use of reusable bottles from the initiation of oral feeds to decrease LOS.
An interactive welcoming learning environment……with multiple planned times for dialogue and questions, problem-solving your patients, sharing our collective wisdom, discussing the evidence-based research…and our shared clinical challenges.
Our discussions will include critical thinking for all our patients, no matter the age. It’s not just learning “what to do” clinically but thoughtfully considering what not to do and why. Because every feeding experience matters………
I think many of us reading this article might find the beginning overwhelming. unless you are very into complex neurobiology. I am nerdy and I still felt that way in the beginning. But if you skim along in the early parts and hang in there until you get to about page 10, from there on you can extract key little nuggets that can inform our practice. These little nuggets I hope will help us speak from a perspective of knowledge and advocate for intervention, and make better sense of the infant’s/child’s history before us, seeing them through a different lense. I hope these nuggets inform your feeding/swallowing practice, whether in the NICU, EI or even in the adult world—yes, there are enduring sequelae from prematurity. Even if you don’t work with preemies, our former preemies land on our doorstep as toddlers, children and indeed adults whose presentation may be related to early cerebellar dysfunction.
Muehlbacher, T., Dudink, J., & Steggerda, S. J. (2025). Cerebellar Development and the Burden of Prematurity. The Cerebellum, 24(2), 39. (Full text available on Google Scholar)
Here are some takeaways I found when they finally highlight the implications for function: particular co-comorbidities increase cerebellar risk; the connection between an increased incidence of autism in former preterms and cerebellar dysfunction; the association of h/o NEC with smaller cerebellar volume; that corticosteroids for CLD — often a common form of treatment in the NICU — slows cerebellar growth (and clinically both in the NICU and beyond, our infants with CLD seem to have the most challenges with suck-swallow-breathe coordination); the potential correlation between hypoxia-induced white matter injury affecting cerebellar volume and complexity of dendrite formation in animal models; large PDAs resulting in altered blood flow associated with cerebellar hypoplasia and changes in cerebellar micro-structure; a prospective study in very preterm infants showed that nutrition via breast milk compared to formula-fed milk improved cerebellar volumes; that there is increasing evidence for the importance of early brain activity for development of neuronal survival and formation of brain networks; a follow-up study of former preterm infants with isolated cerebellar injury demonstrated on MRI at three years of age an impaired growth of several cerebral regions affecting both gray and white matter— and the impeded remote cortical development after isolated cerebellar injury was linked to domain-specific functional deficits in neurodevelopment; intrauterine cerebellar growth reaches its peak during the third trimester, from 24 weeks to around term equivalent age —after preterm birth, cerebellar growth is still rapid, but several studies using ultrasound or MRI have reported that postnatal cerebellar growth in very preterm or extremely preterm infants is impeded, resulting in a ‘cerebellar hypoplasia of prematurity’; several neurodevelopmental outcomes at seven years including IQ, receptive language and motor function were positively associated with cerebellar volumes at term equivalent age and at seven years, and increased cerebellar growth was correlated with better neurodevelopmental outcome at seven years; A small study compared a cohort consisting of 22 preterm infants born between 28 and 33 weeks and without major comorbidities (considered as “low-risk” for neurodevelopmental impairment) with 24 term controls–the “low-risk” cohort still had smaller cerebellar and hippocampal volumes and a smaller corpus callosum on MRI at nine years of age which correlated with worse attention and executive functions in the preterm group; autism spectrum disorder has a high prevalence in preterm infants and core autism symptoms are associated with regional volume changes in the cerebellum; perinatal cerebellar injury is the largest non-hereditary risk for autism with a 36-fold increase while prematurity < 32 weeks still increases the risk 7-fold; adults formerly born preterm had persistent cerebellar dysfunction up to adulthood in a study, even in the absence of early direct cerebellar lesions.
QUESTION: Currently have a 6 y/o pt on an inpatient rehabilitation unit. She is trach and vent dependent following necrotizing pneumonia. She is allowed to have cuff deflated 3x/day and can use a PMV while cuff is deflated although she is only tolerating for approximately 30 minutes a day. Getting ready to do an mbs, would you assess pt with cuff down and speaking valve on in addition to cuff inflated? Do people generally wait until a pt is able to tolerate speaking valve for a certain amount time prior to taking pt to mbs. Is it always safer for a trach patient to eat/drink with speaking valve inline? We are having some disagreements on the treatment team. Thanks for your advice/opinions.
CATHERINE’S ANSWER: We don’t know much about her history and other co-morbidities, which might affect next steps and treatment plan. But given what we know: it’s great that she is tolerating cuff deflation and is tolerating the PMV for 30 minutes at a time apparently with adjustments in ventilatory support. While in radiology, I would also observe her with the cuff deflated and the PMV in place. That will give you some objective data about the effect of the PMV on swallowing physiology in comparison to physiology without the PMV in place. Typically in pediatric patients we do often observe better driving force on the bolus and better pharyngeal clearing, likely associated at least in part with restoration of subglottic pressure. Also, the restoration of taste and smell is critical for our pediatric patients to help either normalize or enhance the oral-sensory system, which is such a critical variable in both healthy and medically fragile pediatric patients. Even to initiate safe tastes, and hopefully brief/small PO feedings, this data will be invaluable. If your RTs are closely involved with PMV, keeping them a spart of the problem-solving team will be beneficial.
The most recent study that looked at this specific question was in Laryngoscope 2013 (Ongkasuwan et al, “The effects of a speaking valve on laryngeal aspiration and penetration in children with tracheostomies”) concluded the PMV did not demonstrate a decrease in laryngeal penetration or aspiration. However, this was small sample with quite varied ages and indications for tracheostomy. Most unfortunately, the study only looked at occurrence of aspiration and penetration. As Bonnie Martin Harris has so wisely stated, aspiration and penetration are neither sufficient nor necessary for a swallowing impairment.
So for this discussion, it reminds us that in radiology with this child it will be important to look beyond the effect of the PMV on just “aspiration” and “penetration”. Consider its effect on her swallowing physiology, and its components, which underlie safe bolus transport.
Let us know what your impressions are, Stephanie, so we can further inform our clinical wisdom.
QUESTION: What slow flow sippy cups do you recommend?
CATHERINE’S FOLLOW-UP: Can you tell us more about the patient for who you are selecting the sippy cup? Since the cup is to be a therapeutic tool for the child, understanding the bigger picture is essential for targeting a cup that might be a potentially safe intervention.
THERAPSIST’S RESPONSE: Still on bottle, over 18 months, Down Syndrome dx. Silent aspiration across thin, 1/2 nectar, nectar so thickening not effective. Not a candidate for NMES due to pacemaker. Can extract from a straw but spits instead of swallowing. What are your slow flow sippy cup recommendations for him?
CATHERINE’S FOLLOW-UP: The question about any feeding tool (in this case, a slow flow sippy cup) cannot (or should not ??) reasonably be answered in isolation, i.e., outside the context of that patient, with the unique history, co-morbidities and data that provide the bigger picture, since no two children are alike. With the history provided (DS, with known silent aspiration) the question takes on new meaning. But the information from the swallow study that we know so far isn’t really helping to determine next steps by telling us only that “there was aspiration” —it’s like a doctor saying to a Mother who brings her child in for being sick, and is told by the doctor “Your child is sick, so we have to do what a sick child needs” and sending the Mother on her way–useless by itself. Please tell me more about this child’s bigger picture…when was the most recent swallow study? What did it tell us about swallow physiology and pathophysiology – i.e., why the aspiration occurred? What interventions were objectified in radiology? What were the responses to interventions trialed in terms of their impact on the pathophysiology (i.e., to suggest how they affect improve safety with that level of thickening)? Did they objectify purees or straw drinking during the VFSS with any specific utensils?
From multiple papers, we know that this population is at high risk for pharyngeal dysphagia and airway invasion—In this study —Jackson, A., Maybee, J., Moran, M. K., Wolter-Warmerdam, K., & Hickey, F. (2016). Clinical characteristics of dysphagia in children with Down syndrome. Dysphagia, 31, 663-671—-Of the 61 patients who aspirated, 90.2 % (n = 55) did so silently with no cough or overt clinical symptoms.so the objective data learned in radiology should help to protect the airway –especially since our clinical impressions can often be inaccurate according to research about clinical assessments. Given what we know about this child already —related to the precarious nature of his swallow, we would need to very cautious clinically and be sure to use what objective data we already have to guide us. It’s possible you did not get any more detail in the swallow study report, and that has tied your hands. If so, then perhaps follow-up with parent permission with the evaluating SLP at the hospital for that needed data. This child is quite complex, and it’s good that you are asking about options and suggestions. I suspect there must be some form of augmentative feeding available — so take time to think this through to minimize risks for him, and for you as well, in this process. Always here to problem-solve further.
QUESTION: Looking for cup suggestions for a 13 month old with History of unilateral cleft lip and palate repairs completed at 4 mos. and 11 mos. of age. Currently takes in all liquids via bottle, Dr. Brown’s level 4 nipple (no one-way valve needed). Have tired honey bear, reflo, the first year, replay, Dr. Brown’s sippy spout bottle, Nuby silicone cup, munchkin transition sippy cup, Chicco transition cup, NUK hard spout sippy cup, and just an open cup.
The issue is liquid comes out too fast or with a too great of volume. Pt will cough or just spit out the liquid. We have tried regulating the amount and thicker liquids. He can swallow if liquid is regulated in that way. Any suggestions?
CATHERINE’S FOLLOW-UP: Is this an isolated cleft in a child otherwise normally developing, without co-morbidities? That helps sort out possible reasons for what you are seeing clinically and possible next steps and interventions.
THERAPIST’S RESPONSE: correct isolated cleft. Toy ally developing and hitting milestones otherwise.
CATHERINE’S FOLLOW-UP: What is his previous experience with liquids since birth? Purées? I ask because every surgeon has different restrictions pre/post op. Wondering if this is experiential, combined with decreased motor learning, maybe with some sensory preferences within the typical range — or perhaps outside the typical range??
THERAPIST’S RESPONSE: Feeding tube for 24 hours after birth. Dr. Brown’s bottle with specialty valve insert until 4 weeks ago. Puree stated at 6 months of age, started feeding therapy to resolve immature swollen pattern, anterior spillage and poor tongue lateralization. Was able to take bottles after each repair. Post-palate repair able to eat puree with no issues. Continued exposure to different textures. Can self-feed following BLW approach. Eats Cheerios/puffs lien a champ. Reducing bolus size when offered large item (like sheet of graham cracker) still developing. I’m thinking it is experiential and sensory. He uses his finger to complete lateral sweeps and pick up anterior spillage. We don’t know what nerve sensation he has in his mouth. He is still cutting teeth. PCP wants him transitioning off bottles soon. Just can’t seem to find a cup that has a reduced enough flow to even give him experience with drinking out of something other than a bottle.
CATHERINE’S FOLLOW-UP: It’s uncommon that with an isolated cleft one would see anterior spillage and poor tongue lateralization, the need for caregiver to break graham cracker sheet into smaller pieces, and the need for finger for lateral sweeps still —-especially with such opportunities as you describe, and BLW along the way. Those differences, combined with no success with multiple utensil trials makes me wonder if there are some differences in lingual integrity that underpins tongue-palate seal, lingual thinning and cupping, decreased intrinsic lingual muscle ROM for lateral shifting…wonder if perhaps a tongue tie? My colleague Laura Brooks from Children’s Healthcare of Atlanta published an article that suggests a potential correlation between altered swallowing physiology and restricted BOT secondary to posterior tongue tie. I wonder if that is relevant to this clinical presentation. It may not be.
Brooks, L., Landry, A., Deshpande, A., Marchica, C., Cooley, A., & Raol, N. (2020). Posterior tongue tie, base of tongue movement, and pharyngeal dysphagia: what is the connection?. Dysphagia, 35(1), 129-132.
Can you tell me more about those oral-sensory-motor components —- I wonder if we figure out the “why” and then focus on a cup that averts the resulting coughing or anterior spillage You’ve tried so many cups , wisely so, and the child also has trouble with chewing except with essentially meltable items… I don’t think it’s the cup– it’s what the child brings to the task, or what he might not yet have learned…. Something is missing in this puzzle. Sounds like the nature of his challenges point away from just “experience”, and perhaps both sensory and motor pieces. It’s not typical to experience loss of nerve function related to cleft repair. Thanks for all the detail as we think this through, and for your clinical wisdom, not typical of an “isolated cleft”. Sorry for so many questions but my they help me sort it all out.
CATHERINE’S FOLLOW-UP COMMENTS… Not sure about the outcome for this child as there wasn’t further conversation, but the key take away…It typically isn’t about the utensil but the bigger picture. Peeling apart the multiple pieces, slowly and methodically, is the way we arrive at “the why” and what the next steps might be for each unique infant or child with whom we are blessed to work.
