Problem-Solving with Catherine: Complex One-Year-Old Post VFSS


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I have a question/need help please! A patient recently was added to my caseload. Another SLP at a different facility completed his MBSS and notes no aspiration but flash penetration with all liquid consistencies.  The family was recommended to thicken liquids to nectar thick with oatmeal, and for us to trial weaning from NTL. My facility is not familiar with IDDSI recommendations or thickening with oatmeal.

Is anyone familiar with thickening with oatmeal, and if so, what guidelines do you use for measurement? (What’s the ratio for thickening with oatmeal?)

Also, the patient just turned one year old. He presents with lingual and labial restrictions and consistent open mouth posture. Parents were told by an ENT his mouth is “perfect” so despite my recommendations for a second opinion, they refuse to. They also refuse e-stim therapy to help target pharyngeal phase deficits.

The SLP who completed his MBSS also recommended they go down to a Dr. Browns Level 1 nipple for thin liquids. We have been working on oral phase deficits; however, I feel we are at a plateau due to things behind my control (anatomy). Any recommendations on how to proceed?


Catherine’s Answer:

Missing info both about history, co-morbidities, and specifics from VFSS which makes it hard to problem solve. Without that data we might just be guessing and selecting interventions that don’t align, might be unsafe or contraindicated. You might not have been given that info but it is key to problem solving—- All we know is there was flash penetration and no aspiration —that doesn’t help much because we are missing information about physiology/pathophysiology —but you mentioned “oral and pharyngeal phase deficits “ in passing — the open mouth posture and other issues may be related to nasal airway patency, hypotonia, poor postural control, global impacts of TOTs, and multiple other factors that may be identified through his history and clinical presentation. That he did not aspirate doesn’t mean his swallowing physiology isn’t precarious —in the setting of his co morbidities (which we don’t fully understand). Recent research at Boston Childrens suggests laryngeal penetrations in the setting of co-morbidities are not necessarily benign — meaning they may benefit from interventions. Not necessarily thickening but even change in utensil or rate of drinking to avert the penetrations. All that should be problem solved during the VFSS including best way to avert penetrations and improve the dynamic swallow. And thickening is a last resort, so we hope other interventions were trialed and objectified. If thickening was the only option left, objectifying the best way to do that while under fluoroscopy is essential. Because clinically we would be guessing at what “works” since we can’t objectify impact of the possible interventions. And that is why starting a weaning of the thickened liquids isn’t the first or next consideration in managing this patient. Too many missing and moving parts. Sorry I don’t have suggestions yet —my mind is moving out of necessity to lots of questions to help me then consider potential solutions. Pause and look again at what pieces are missing, gather that data, consider that based on history and comorbidities, and clinical behaviors.


Catherine Shaker Seminars: Elevate Your Infant Feeding Practice

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Join Catherine Shaker to take your infant feeding practice to the next level. Whether you are in the NICU or in Early Intervention, key information you can use right away with infants on your caseload. Indy in July and Baltimore in August

  • NICU Swallowing and Feeding: In the Nursery and Early Intervention July 22-23
  • Neonatal/Pediatric Video Swallow Studies July 21
  • The Early Feeding Skills Assessment Tool: A Guide to Cue-based Feeding in the NICU: August 29-30

In the NICU Seminar and Early Intervention, critical thinking and problem-solving based on real life infant clinical experience over 45 years. Latest research. Assessing and treating complex sick newborns and preterms with swallowing feeding challenges, trachs, tubes in the NICU. Foundations for supporting the complex infants discharged to you in EI from the NICU. In the Video Swallow Studies Seminar, focus on the entire swallow pathway and its potential for compensations and maladaptations in relation to co-morbidities, from birth on. Looking at the evidence-base, the big picture, and use of critical reflective thinking, not a cookbook approach; even if you don’t “do swallow studies” increase your understanding and be more skilled at referrals. In the Cue Based seminar, Dr Suzanne Thoyre and I do a deep dive into infant-guided cue-based feeding, the evidence-base, complex feeding challenges in the NICU and after discharge in EI. Analyze and score videos of infants feeding and problem-solve next steps.



Problem-Solving with Catherine: 15-month-old with TOTs and Difficulty Chewing

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What am I missing? 15m old, chewing crunchy things, meats and starches (muffins, toast, fruit breads) and swallowing without difficulty. Drinking juice (not water) from a straw. Eating dried fruits and snap pea crisps well. But fresh fruits and veggies, we are making almost no progress. Will put most trials in his mouth, chew then push out, then refuse further attempts. Likes yogurt but refuses all other purees. No trouble with getting hands messy. GI had no concerns, did an MBS with no notable findings. Frenectomy recommended by ped dentist to be done soon.

Catherine’s Answer:

Is he otherwise normally developing without any feeding history that sounds worrisome? What is his overall sensory system like? Any history of reflux? I wonder about the swallow study results and data that was obtained. While there apparently was no witnessed aspiration, did they describe swallowing physiology in the findings? That data can provide more information about muscular synergies and the multiple components that underpin chewing that might be problematic. It is not uncommon for swallowing physiology to be altered in the setting of tethered oral tissues, but there may be other findings from the swallow study that could shed light on the “bigger picture”.  The ability to recruit full ROM for chewing a full variety of foods may be sensory-based, motor-based, and/or due to the impact of the altered ROM of the check/lip/lingual muscles due to tethering, and/or a combination of any of these. Take a careful re-look at oral-motor control and preferential foods/liquids to help you peel apart what might be the “why”. The sensory “load” from the foods that child is successful with, and the bolus control required, and also the co-occurring muscular requirements for posterior bolus formation and full ROM for BOT retraction, are key considerations. It’s complex, so pause to sort it out and figure out the “what else” that might be impacting what you are seeing. The apparent need for a release is clearly a factor in your differential, but like a “detective,” now focus on if there is anything else that underpins function that might be aberrant. It may be that the release planned will not in and of itself promote normal eating patterns; I suspect that is unlikely. Whether there is perhaps also learned maladaptive oral-motor behavior and other reasons for his preferences will need to be sorted out and treated to support optimal feeding outcomes.




Catherine Shaker Seminars 2023: Real World Learning

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Join me for multiple advanced clinical learning opportunities! Clinically relevant, rooted in evidence-based practice and critical thinking. Immediately applicable. Enjoy a welcoming environment that fosters interaction and learning along with each other. Remaining 2023 locations:  Indianapolis (July), Baltimore (August/September), Yonkers NY (September), and Boston (October). This will change your practice.

  • 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 and 

Our discussions will include critical thinking for all our patients, no matter the age. It’s not just learning “what to do ” clinically but the weaving in of compassionate family-centered care, which must go hand in hand with the clinical expertise we bring. So that every feeding experience matters. It is, as one of neonatologist mentors told me years ago, all about finding the balance between the art and science of what we do. The communication from the infant, the child, and the family must always be the lense through which we problem-solve and intervene. Each of us has had a moment when we really “listened”, and it changed our practice forever. Mine was in 1985, with a wonderful mother of a critically ill preterm infant, and it has stayed in my heart. This relationship-based nature of our work, and its potential to influence lives in so many ways, must remain as much a part of our day-to-day interactions with families, always inextricably linked our problem-solving.

Problem-Solving with Catherine: Where to Begin with Former Preemie with Multiple Complex Co-Morbidities

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I’m looking for some insight on where to begin with this case:
The child’s age is 4 Months (Preemie Baby – 35 Weeks, will be 5 months soon). Aspiration pneumonia, G-Tube and Nissen Fundoplication, nothing by mouth.
Issues with swallowing – risk of saliva entering to lungs – can’t give him pacifier, reflux, and unknown genetic abnormality/corpus callosum. Any help would be appreciated!

Catherine’s Answer:

Sounds like he is a late preterm who is going to be 5 months soon and would then be not quite 4 months adjusted age.​ The neurologic co-morbidities (absent corpus callosum) suggest at least part of the etiology for the abnormal swallowing and that often results in altered oral-pharyngeal reflexes that underpin feeding. There may be other components of his history that might further inform a differential to guide a plan of care. I would suspect there might have been a VFSS early on in the NICU unless he was so neurologically devastated that the team determined a VFSS would not change his management and proceeded with a G-Tube/Nissen; or if he did not swallow his saliva, we would likely not do a VFSS. High risk for altered postural control so will benefit from neurodevelopmental treatment to facilitated base for supporting motor learning. Oral-sensory-motor intervention will be key to support learning to swallow saliva; this often involves using a pacifier as one component. When cautiously and thoughtfully utilized, it can help facilitate the intrinsic tongue control for swallowing saliva and oral-motor organization.

To start problem-solving, it will be helpful for me to understand what you see clinically, especially related to postural and oral-pharyngeal tone, oral-pharyngeal reflexes, interest in own hands to face/ mouth, need for suctioning and response to suctioning, any spontaneous swallows observed, any ENT consult results.

Very challenging patient with multiple complex issues that are likely to be enduring and progress likely to be slow.

I hope this is helpful.

Problem-Solving with Catherine: Repeat Swallow Studies

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How often are swallow studies typically repeated? Yearly or just when there is a status change until not needed?

Catherine’s Answer:

Since our goal is to minimize radiation, especially with infants, it’s key to look closely at the risk-benefit ratio of a repeat study. Most often that means: if there is decline in swallow function despite following recommendations from most recent study; if there is a change in patient status (illness, new co morbidity, regression in overall skills, consideration of G-Tube removal or decannulation for example); if the results from the most recent study were tenuous or based on limited or inconsistent data, or the SLP lacked confidence in the results; if there were technical problems ( unable to record so review of physiology not possible leaving results less assuring) for example. When we lock ourselves into an arbitrary number of weeks or months for a repeat study, then our clinical thinking can become arbitrary and generic instead of based on that patient’s unique history, co morbidities and clinical impression as to how fragile swallowing physiology is — even with interventions. Especially when we consider that child’s feeding environment (need for modifications, parent follow through and fragility of medical status, for example). The decision about timing for each child will be unique. It’s a good reminder about avoiding arbitrary points in time for anything in our clinical planning/practice. Your unique patient is always the guide.


Problem-Solving with Catherine: School-aged Child with MD

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Looking for suggestions. What (if anything) would be safest to offer a Kindergarten student with Muscular Dystrophy that has ongoing respiratory concerns (and is frequently absent as a result), currently maintains all nutrition via G-tube due to some choking episodes when fed at home and is seated behind a shield with his nurse and instructional assistant on either side. Family is insistent on having him engage in an oral experience during lunch with his peers and is suggesting a Tootsie pop which should be taken away before he gets to the candy which I am not comfortable with at all. There are no doctor’s orders on file, and we cannot demand them. Any ideas or discussion would be greatly appreciated.

Catherine’s Answer:

I would not offer anything PO, based on both child’s diagnosis and the history we know of, without an instrumental assessment of swallowing physiology and subsequent physician orders. I would be documenting that in the child’s record as my current recommendation based on information currently available, with a documented phone call to the MD, and the MD’s direction. And I’d pull in administration/my leader from the start. The risk appears quite high for airway invasion from what we know, which is limited but well presented. Although the parents want the child fed, I would not proceed. The risk for you is worrisome. As an expert witness in previous similar cases where there was an unintended adverse event, I would otherwise be concerned about potential liability for you. It can happen, unfortunately.


Problem-Solving with Catherine: NICU Infant with NAS/NOW and Cleft Palate

Cleft Palate & Cleft Lip in Babies: Signs, Causes & Treatment

Question: I have a patient in our NICU with a left sided cleft palate and lip. The patient developed ulcers on the exposed palatal shelf, which are suspected to be due to “mechanical trauma” from feeding. We we’re initially using Dr. Browns specialty valve bottle. We switched to the Haberman bottle to see if this improved the situation, but they did not heal and seem to become more irritated as he feeds more.  We have now stopped feeding and plan to re-assess once the sores have healed. The patient has shown ability to safely feed with both the bottle systems we’ve used thus far and loves to eat!

I am being asked if there is a different bottle system that may prevent “friction” against the palate. I’m not sure a different bottle system would make a difference but have never come across this situation before. I’m having trouble finding any research regarding feeding-related ulcers in cleft palate cases. Dermatology has been consulted and agrees it is likely feeding related. Have you come across this before or have any suggestions that may prevent further irritation of these areas??

Catherine’s Answer: I too have seen this unfortunately, though it is not a common co-existing issue for most infants I have followed with a cleft palate (both in the newborn Nursery and in the NICU). My initial thought is that it is uncommon for an isolated cleft in an infant admitted to NICU to delay discharge by a month; if there is an isolated cleft, most infants with proper support become full PO feeders within about 48 hours, in my experience.  It makes sense as I then read your follow-up info, that the co-occurring co-morbidity of what sounds like NAS/NOW may be further complicating the provocation and persistence of the ulcers. Is the infant preterm as well?

Things I am thinking about. Both prematurity and h/o NAS/NOW with sequelae, potential other co-morbidities, and how the infant is being fed could all be factors.

Optimal motor learning in utero is adversely affected by preterm birth, regardless of the cleft. That makes the infant’s adaptability to the nuances of sucking and feeding more precarious. If there is any increased WOB relating to prematurity, that may interfere with a functional sucking pattern (adaptive behavior to stop flow to allow for a breath). State dysregulation, if present, may predispose a well-intentioned caregiver to “passively assist” or prod the infant with could create further friction.

Also, the infant’s oral-motor integrity that underpins sucking may be altered due to a tongue which lacks good midline stability for stripping; this is not uncommon in the setting of cleft palate. It may be due to lack of motor learning in utero. In utero, there is the likelihood that the tongue “stabilized in the clefted space” instead of the typical intrauterine tongue-palate contact that builds midline stability during sucking and swallowing of amniotic fluid. Does that make sense? For the typical fetus, that motor learning is why feeding emerges apparently effortlessly in the typical newborn. The presence of the cleft in utero creates an altered sensory-motor plan that then impacts function.

This would then potentially lead to a loose and disorganized latch and seal of the tongue on the nipple. If the caregiver doesn’t actively stabilize the nipple in midline (which best supports effective compression for fluid transfer), there can be friction created by repeated attempts of the tongue to latch. As Lauren suggested, stabilizing the nipple in midline can help the infant organize and achieve a stable latch that recues friction. I have heard some bedside caregivers suggest putting the nipple in the clefted area during sucking; assuring this isn’t happening will avoid some undue friction, as well promote more normal oral-motor patterns.

I would also suspect that a co-morbidity of NAS/NOW could further predispose the infant to disorganized sucking pattern that creates more friction due to less stable lingual contact with nipple. State neuro-dysregulation common in infants with NAS/NOW may provoke disorganization that further complicates potential for friction.

If there are co-occurring co-morbidities structures (mandibular hypoplasia, tethered oral tissues) that can also affect lingual patterns at rest and with function. Unclear if this is a concern with this infant.

Multiple potential factors to consider. Depending on the “why” that you determine applies to this unique infant, possible interventions might include: introduce post-feeding oral cares that maintain mucosa for future repairs and minimize dryness (our maxillofacial surgeon asks caregivers to sweep the intraoral structures with EBM or sterile water to clean off any formula and optimize tissue hydration for ease of future suturing). Stay with one feeding system for motor learning (Dr Brown’s best allows infant-guided feeding as it cannot be squeezed by well-intentioned caregivers). Continue to work closely with nursing and family via guided participation (during some PO feedings for one-to-one learning) re: stabilizing nipple in midline and why, avoiding prodding, using infant guide rooting response to help infant optimize tongue placement at the start, provide required swaddling and stability and vestibular/tactile input that promotes state regulation, discuss benefits of lanolin-based cream with pediatric dermatologist who is following and neonatologist, honor infant’s disengagement.

This can be challenging, as many caregivers have their own approaches that may not be optimal for this unique infant. Maybe a neo or APRN can work with you, and you can be present at rounds for a few consecutive days, and have a few key nurses on each shift that “get it” and perhaps become the infant’s primary nursing team to support continuity of care and partnering with ST.

I hope this is helpful. Good he has you in his corner.


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Remaining 2023 Locations:  Indianapolis, Baltimore, Yonkers NY and Boston

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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 and asks and seeks answers to the “why” questions. And 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.

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  • 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

Locations for 2023: Miami, Indianapolis, Baltimore, Yonkers NY, Boston

Problem-Solving with Catherine: “What Else” to Consider in a Differential

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My friend was induced at 37 weeks due to concerns for gestational HTN. She had a maternal fever and leukocytosis during labor and received ampicillin. She had a vaginal birth with baby’s initial APGAR of 6 followed by 8 and 9. After birth, her baby received phototherapy for ~8 hours for jaundice and was then discharged shortly after.

Pediatrician at follow up appointment noted a “squeaky” cry and diagnosed him with laryngomalacia as well as an anterior tongue tie. He had a frenectomy done at 1 week by ENT. ENT also noted a lip tie and recommended re-assessment in 1 month.

He exhibits a “low tongue posture” and sometimes an open mouth posture when sleeping. He is gaining weight but has difficulty with establishing and maintaining latch, especially on left breast. He tends to use a “biting” pattern rather than a sucking pattern, which seems to be impacting efficiency with intake. My friend has been using cross cradle and football positions to optimize latch. He has been unable to latch in laid back position. Stridor? (“squeaking” noises) during breast feeding on the left breast > right. Baby is also exhibiting occasional episodes of apnea when coughing on secretions and is coughing with burping intermittently, which pediatrician attributed to GERD. Frequent gas and spit up. Poor sleeping during the day unless on parent’s chest of in semi reclined position. He is currently 3 weeks, 3 days old.

Her questions are:

  1. How can she help him improve his latch, especially on the left?
  2. How can she help him to reduce stridor (“squeaking” noise) during feeding, especially on the left?
  3. Are there any exercises to help him improve lingual strength and tongue to palate elevation?
  4. Any tips on reflux management without using medications?


Catherine’s Answer:

His early medical history sounds fairly unremarkable with the exception of the “squeaky voice. I find pediatricians not uncommonly “diagnose” laryngomalacia when they hear “stridor” but there can be many etiologies for stridulous voice in an infant, and its presentation (e.g., heard only during feeding, vs. heard also at rest). It is true as the pediatrician stated that the stridor may also be a by-product of responsive protective closure to EER/LPR events.

Did ENT scope the infant, and did he/she then diagnose the infant with laryngomalacia? Did ENT report seeing any erythema or suggestion of reddening of the larynx (which may suggest ongoing EER/LPR?) If so, not uncommon then for ENT to recommend some meds. Meds have been reported to reduce inflammation and irritation to tissues and restore laryngeal sensation, in some infants. I suspect ENT did not see evidence of EER/LPR, because you mentioned only the TOTs. Did the ENT clip to release the tongue tie or laser? Laser tends to have a better result. Wonder if the “low tongue posture” may be a posterior tongue tie that was missed? Or may have other etiology. The clinical behaviors you report are c/w sequelae from a posterior tongue tie as one possible etiology. The limited ROM of the upper lip (due to tethering) can also impact the entire oral-motor and hyo-laryngeal muscular network that underpins feeding/swallowing, and create the challenges being observed. Research and clinical observation have suggested a correlation between posterior tongue tie and EER/LPR (air is ingested with each suck-swallow d/t an ineffective seal with the nipple); this can be recruited at breast or bottle.

Tethered oral tissues can often co-occur with mandibular hypoplasia, and in such circumstances, if the tethering is released, it can provoke glossoptosis and airway obstruction. This reinforces the importance of always focusing on the bigger picture perspective, using thoughtful reflection and not signal reacting to a single finding, without considering the context, when we complete a differential.

What to do is not fully clear due to multiple pieces that seem to be contributing our differential (TOTs, EER/LPR, potential influence of airway/laryngeal integrity, possible mandibular hypoplasia). A clinical swallowing and feeding evaluation by a pediatric SLP with experience with complex infants is the place to start. With clinical observations there will be more questions and paths to discovery of what to do.

I hesitate to suggest strategies without understanding what is causing what, as it like shooting in the dark. The stridor may resolve with management of EER/LPR, once we understand its etiology. Ineffective tongue-palate seal and air swallowing may be reduced by release of a posterior tongue tie. There may not be a clear indication of need for lingual strengthening base on what we know so far, but there may, pending the SLP assessment. The “whys” behind each of the concerns so thoughtfully articulated need to be peeled apart to find the “what to do/interventions” that best meet this infant’s needs without a generic response about interventions “to try”. In the interim I’d be happy to talk with your friend about some possible interval inventions that might ease the feeding process. She’s lucky to have you in her corner.

For infants presenting like our little one above, my IBCLC colleagues sometimes trial a nipple shield, bodywork, craniosacral and myofascial interventions in addition to positional changes to impact the altered fascia and postural mechanism. Although it’s not optimal, if intake and weight gain become concerns with breastfeeding challenges, consideration of interim supplemental bottle-feeding has been successful via a Dr. Brown’s controllable flow nipple (a similar as possible to the controllable breast flow), adding in the blue valve (to avert energy depletion given what sounds like infant’s predominant compression-only sucking pattern). Lots of moving parts for this infant’s bigger picture that will benefit from a skilled pediatric SLP’s eye.

Problem-Solving with Catherine: Infant with “Failed” Swallow Study

Brain tricked into thinking it is fasting to cope better with inflammation

Question: I am looking for research on aspiration and breastfeeding as well as breastmilk from a bottle. I have a 3-month-old that failed swallow study with even honey thick and hospital recommended thin breastmilk in bottle. I am more comfortable with breastfeeding, that gives more control than with bottle feeding. Thoughts?

Catherine’s Answer: Aspiration isn’t just aspiration…the “why”, i.e., understanding the pathophysiology of the swallow, in the setting of the infant’s co-morbidities is essential to determine the best plan for that unique infant. Otherwise, we do the same thing with all infants who “aspirate” and that would not make sense and would be unethical. It’s possible you don’t have that data, although the SLP conducting the VFSS should provide that so you can target your interventions. “Thickening” isn’t a plan for intervention, it’s a step along the way, to buy time for improvement. If you aren’t getting that data from the facility who does your swallow studies, I’d refer elsewhere. A result that says there was “aspiration” is essentially useless as a treating clinician. It’s like the pediatrician telling a mother in his office “yes your child is sick”, and then sending her on her way. useless really. Depending on the data set, your plan of care can vary. A healthy normally developing newborn with the same presentation in radiology is very different than a former preterm infant for example, who has CLD and a paralyzed vocal cord. Also agree that honey level thick (to use non-IDDSI terminology) likely increases risk to invade the airway –if the physiology of the swallow is that impaired, then the likelihood of aspirating honey thick is quite high during the course of a true feeding. Have you contacted the evaluating SLP with parent’s permission to better understand her recommendations and rationale? That might be a place to start too. Lots to unpack here. We also know we cannot extrapolate (from results in radiology of bottle feeding) to assume we understand swallowing physiology at the breast. That is not possible. FEES is our closest source of information, and even so, we cannot fully observe the full dynamic swallow pathway due to “white out”; we can however infer some useful data from FEES pre-swallow and post-swallow information to help guide our interventions. Some missing pieces would help problem-solve this little one. Also, no intervention can be considered in isolation — there is a risk-benefit ratio for each patient that we must consider when selecting interventions. Depending on the etiology and co-morbidities, breastfeeding may indeed be protective, under some conditions more than others.

Problem-Solving with Catherine: Poor PO Feeding in Former 25-week Twins

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I have not seen this family yet, but here are their concerns. They didn’t specify the babies’ current age but I’m guessing a couple of weeks out from being discharged at 44 weeks so their corrected age would only be about 6 weeks. Would love any guidance in how to best support this family!

“Twins born 25w, used to take 100ml per feed in NICU when they were 36weeks – 44weeks. Their feed has been declining since discharge at 44 weeks. Recently 30-70ml per feed, only hitting 50-70% of daily total volume goal. Both would get fussy/mad often during feed and fall asleep a lot. We have already changed the formula a couple times as suggested by our pediatrician, but they don’t seem to behave too differently. We use fortified breast milk 24 calories per oz with the formula. Started with Neosure (used in the NICU), tried Enfacare for a few days, and changed to Nutramigen for the last two weeks.”

Catherine’s Answer:

We don’t know much about history but hearing that they are former 25 weekers suggests strongly to me that there is a high risk for respiratory sequelae, which may be why they are disengaging during feeding; it is likely purposeful and adaptive behavior. There may be GI issues that could be related to many possibilities—such as gulping leading to air ingestion, tethered oral tissues that create air ingestion with each suck – both possibilities could provoke GI discomfort.  Parents may have increased the nipple flow rate since being home (to increase intake) which may be actually reducing their available breaths and leading to depletion of reserves and making intake worse. It’s all about the aerobic demands of feeding and the co-morbidities that underpin function. And it is also possible the intake noted in NICU was due to well-intentioned volume-driven feeding, sadly, and maybe now parents – hopefully- aren’t “pushing them”. When you evaluate the infants, be watchful for infant communication (physiologic and behavioral stress signs), how parents feed (flow rate, position, consideration of state, their response, or lack of response to infant disengagement, how developmentally supportive the feeding experience is – or is it volume-driven, what they describe would be a “good feeding” (i.e., bottle empty, awake at the end, stays awake, seems to like it). May experience tells me that volume-driven feeding combined with respiratory fatigue may be what’s going on. Parents will then need gentle (and the “whys” behind your suggestions) to unwind that volume-driven approach and move to infant-guided feeding (more manageable/slower flowrate, swaddled elevated sidelying, contingent resting, contingent co-regulated pacing). Close contact with the pediatrician will be essential. Re-admissions due to FTT post NICU discharge are high in this group, who often present as fragile feeders in the NICU and after discharge too. There is also a high risk for silent and symptomatic aspiration in this group, which may also be a part of the bigger picture adversely affecting feeding.



Catherine Shaker Seminars 2023: Real Time Clinical Problem-Solving

Instructor brain

Join me for multiple advanced clinical learning opportunities! Clinically relevant, rooted in evidence-based practice and critical thinking. Immediately applicable. Enjoy a welcoming environment that fosters interaction and learning along with each other. Remaining 2023 locations: Indianapolis, Baltimore, Yonkers NY, and Boston.

  • 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 and 

What you colleagues are saying: “This was the first “advanced” course I’ve attended that did not waste time reviewing “beginner” info. Most advanced courses do not provide functional therapy ideas or go into such high-level detail and with different evidence-based approaches in such a dynamic way” Anita, SLP

“Real time clinical problem-solving and how I can take pieces from a variety of approaches and individualize them for the infants and children I treat. Loved the group discussion and the up-to-date research”. Stephanie, OTR 






Problem-Solving with Catherine: Two-Year-Old Gagging with Textured Foods

hand puzzle


I have a 2 year 6-month-old child who was NPO and G-tube dependent until he started feeding therapy again about 5 months ago. He is safely able to consume thin liquids and IDDSI level 4 solids like pudding with no issues. Recently, I’ve started to try textured foods with him. I’ve noticed that he will accept the food into his mouth and chew it up, however, starts gagging shortly thereafter and spits it out. I don’t believe it’s a swallowing issue, but rather a sensory issue and it seems the texture of chewed up food makes him uncomfortable. Does anybody have any advice/tips on how I can help him with consuming textured foods? TIA!

Catherine’s Answer:

To help problem-solve, can you round out the bigger picture, as that is likely key to first understanding the “why” behind what he is doing, to then figure out interventions. At 2 years 6 months, is there a history that will help explain some of this? For example, why was a G-Tube placed? Was he born at term? What are his diagnoses? GI issues? Sensory Processing Disorder? Does he have atypical motor and/or postural and/or sensory-motor issues? Cognitive/communicative status? TOTs? h/o “release” of TOTs? Clarity of connected speech? Was there ever swallow study and what did it reveal about physiology? Is he gaining weight? One of my colleagues wondered if there may be any tonsillar hypertrophy that could create challenges with textured foods; any apparent challenges with thicker purees that may suggest that etiology as well?  It’s very possible that his responses are adaptive behavior, i.e., purposeful, and due to reduced strength and motor control problems. If so, that will be your treatment focus. You are asking good questions. It’s ok to take the time to figure out the why and ask yourself more questions about what you are seeing and the possible reasons. Otherwise, you may select interventions that are not what his system needs, and more maladaptation could be inadvertently fostered.

Problem-Solving with Catherine: Prolonged Pacifier Use in 4-year-old

pile of pacifiers ready for the pacifier fairyQuestion:

I have a 4-year-old who unfortunately has demonstrated significantly violent behavior with parents’ attempts to wean him. He has been significantly impacted on a structural level by prolonged use, negatively impacting both speech and feeding. My gut tells me it needs to be addressed by pediatric psychology.

Catherine’s Answer:

There are likely multiple factors contributing as this is atypical for an otherwise normally- developing four-year-old. What else do you know about his history and co-morbidities? That gestalt will likely offer some key insights that may be relevant.

It is possible the structural differences you observe are a consequence of prolonged pacifier use, but the structural differences may also be co-occurring. Meaning that the structural differences may be separate from the impact of a pacifier and unrelated in their etiology. Or they may indeed be solely due to prolonged pacifier use or exacerbated by it. Understanding any history or co-morbidities that are a part of his “bigger picture” would help peel that apart. As Barb so thoughtfully suggested, there may be reasons from a sensory motor perspective that pacifier use serves “a purpose” for him, meets a “need’ on a sensory level, as our kids at all ages do things for a reason. That may provoke the unbridled response reported when the “answer” to his “need” is taken away. Or it may be a learned behavioral response established in the child-parent relationship.

Without knowing his history and co-morbidities, it is challenging to problem-solve but with what I understand, there is a need for the expertise of pediatric SLP related to feeding and speech. Prolonged pacifier use can alter the oral-motor synergies/components that underpin chewing, swallowing and speech production. I’d suggest a consult by a pediatric OT skilled in sensory integration. The OT will also assess overall sensory motor control/processing, which may be the part of the underlying need that pacifier use is serving and determine if a PT consult is warranted.

At his age there may be a learned behavior and interaction pattern with parents, both related to pacifier use and beyond, that would benefit from the additional expertise of a pediatric psychologist.

Then the three professionals can together problem-solve and develop a plan of care with family involvement that addresses the “why” (postural, sensory-motor, oral-motor, “behavioral”) and a systematic approach to providing, in other ways, what his sensory system needs or “is craving” That may include SLP support for oral-sensory-motor treatment to normalize his oral-sensory system, and promote carryover of that intervention in ways that are more socially acceptable (and more developmentally supportive) than a pacifier, and OT for sensory integration that is perhaps more of a global need for this child than apparent on first glance.

I hope this is helpful.