Problem-Solving with Catherine: Poor Cup Drinking Post Cleft Lip/Palate Repair

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Think along with me, through this dialogue, as we peel apart the pieces of this clinical puzzle…

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.

Problem-Solving with Catherine: Clinical Weaning of Thickened Liquids and Potential Risks

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QUESTION: As a NICU therapist that also does acute pediatrics and outpatient swallow studies, we always have a lot of follow up patients, NICU graduates, etc. I’ve had a lot of infants/peds coming in for follow up swallow studies after “silently aspirating thin and/or slightly” and have been on a thickened diet. The families report their outpatient therapist weaned them off the thickener during therapy and discharged them. They are returning for their repeat MBSS from MD recommendation because it’s “due” or to be “cleared” or because infant with persistent illness, etc. 90-100% of them are still silently aspirating. So question… as an outpatient/home health therapist I’m truly asking for ideas or thought processes for taking patients off thickened diet without follow up mbss (patients with silent aspiration- which is usually always the case). Is it an assumption that they won’t get in? Access? Poor family buy in or follow up? This is NOT a post to stir up division but the opposite. Truly wanting to bridge this gap.

CATHERINE’S ANSWER:

This clinical “conundrum” often comes up during my VFSS Seminar and is a question that asks us to think critically and at the top of our profession.

With any patient on thickened liquids, we always want to understand  the swallowing pathophysiology objectified initially in radiology that led to the need for thickening and how precarious that physiology was, even with thickening. Those infants/children who have enduring multiple complex comorbidities are often silent aspirators. Within this high-risk patient group, we often find the weaning protocol doesn’t build in the objective data necessary to determine the true impact of a change in amount of thickener on swallowing physiology and therefore, on airway protection during a ***true feeding*** (often 30 minutes or more). The objective data from a VFSS about the impact of weaning thickener can be often surprising and indeed is often necessary especially for patients with complex histories…. versus weaning based on subjective/clinical impressions only. The risk-benefit ratio of clinical weaning for each patient must be carefully considered.

The team at Boston Children’s has provided us with research to help inform our practice related to clinical weaning. This paper referenced below details the intervention—a protocol for weaning thickened fluids via clinical data. Its implications are far reaching, however, and its recommendations require critical thinking in their application.

Wolter NE, Hernandez K, Irace AL, Davidson K, Perez JA, Larson K, Rahbar R. A Systematic Process for Weaning Children with Aspiration from Thickened Fluids. JAMA Otolaryngol Head Neck Surg. 2018 Jan 1;144(1):51-56.

Like any other protocol, the key is considering when to utilize a protocol as a guide and considering when not to; that is, when doing so may adversely affect the risk-benefit ratio. My physician mentors over the years have referred to this process as the “art and science of medicine”.  It requires us to ask how we thoughtfully apply the findings of any study to our clinical reasoning for each patient individually, to minimize risk of adverse events.

Clearly our repeat studies according to the AAP must be completed with thoughtful justification and careful attention to risk-benefit ratio, especially with infants. It is best practice as stated in the article that “children should be transitioned to non-thickened diets as soon as it is safe to do so.”

However, reducing fluid thickness solely “based on a patient’s’ clinical response” is worrisome to me.

In pediatrics, like in adult care, patient A is not the same as patient B, even though they both have been placed on thickened liquids for clinically sound reasons. Those infants/children with more complex co-morbidities, those who silently aspirated, and those with more precarious swallowing pathophysiology would potentially have greater risk for airway invasion with changes based on clinical data alone. And there may not be clinical suspicion that the wean increases risk, as the weaning protocol proceeds. Universal application of the weaning protocol without a very clear consideration regarding these fragile high-risk feeders may inadvertently increase risk for airway invasion.

Duncan et al in their 2018 study (Duncan, D. R., Mitchell, P. D., Larson, K., & Rosen, R. L. (2018). Presenting signs and symptoms do not predict aspiration risk in children. The Journal of Pediatrics, 201, 141-146)  reported that “Presenting symptoms are varied in patients with aspiration and cannot be relied upon to determine which patients have aspiration on VFSS. The CFE (clinical feeding evaluation) does not have the sensitivity to consistently diagnose aspiration”. Their findings would likely apply to post-swallow study decisions made without benefit of objective data, and that is worrisome.

Most recently, a team at Boston Children updated its 2019 paper on thickening considerations (see citation below), and among their recommendations was this statement:

“Implementation of a systematic weaning protocol may also result in a reduction in instrumental assessments for the patient which may reduce their exposure to ionizing radiation if re-evaluating via the videofluoroscopic swallow study. However, providers must remain cautious if using this approach in infants and young children with silent aspiration, given the difficulty in monitoring symptom change while weaning in these patients…The balance between viscosity and flow rate in aerodigestive patients with oropharyngeal dysphagia needs to be based on instrumental assessment of swallow safety such as videofluoroscopic swallow study.”

Duncan, D. R., Jalali, L., & Williams, N. (2024). Gastrointestinal Considerations When Thickening Feeds Orally and Enterally. Pediatric Aerodigestive Medicine: An Interdisciplinary Approach, 1-35.

Pados (2019, see citation below) further highlights the importance of assessing a feeding regimen under instrumental assessment: “When thickening of liquids is indicated, providers and families need data obtained from an instrumental assessment to guide evidence based decision-making about the safest thickened liquid consistency and type of nipple to offer to maintain a flow rate that is safe for the infant” (Pados BF, Park J, Dodrill P. Know the flow: Milk flow rates from bottle nipples used in the hospital and after discharge. Adv Neonatal Care. 2019;19(1):32–41).

Perhaps most worrisome is the possible implication from Wolters’ conclusions is the implication  that the value of a VFSS is to identify bolus misdirection and aspiration, rather than to objectify swallowing physiology and pathophysiology as a basis for optimal interventions and their modification. The risk-benefit ratio of a repeat VFSS must indeed be carefully considered, but we must also consider the critical impact of that objective data, about physiology, on any changes in interventions we might consider.

The more I learn, the less black and white answers I have, and I think that is good. For each patient, we will need to continue to develop an algorithm for that patient, that best minimizes risk, in the setting of that child’s unique co-morbidities, history, and the nature of the swallowing pathophysiology objectified. Pausing to consider all the pieces for each unique patient, and reflect, will always be critical.

 

 

 

Catherine Shaker 2026 Seminars! Final Tour…. Registration Now Open

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**   Join Catherine in 2026 on her Final Tour**

….an advanced in person learning experience that you will always remember…

        Long Beach CA,   San Antonio TX,  Fremont CA and Dallas or McKinney TX……..

  • Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and  Practice Issues
  • Pediatric Swallowing and Feeding: The Essentials
  • NICU Swallowing and Feeding: In the Nursery and After Discharge in EI
  • Pediatric Video Swallow Studies: From Physiology to Analysis
Click here for Catherine Shaker Seminars 2026 Brochure
Click here for Site/Location Info

   ***limited space in the Dallas location, so register early!***

 

 

 

 

 

Happy Holidays 2025 from Catherine Shaker 🌴🌴

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HD wallpaper: Dogs, German Shepherd, Artistic, Baby Animal, Oil Painting | Wallpaper Flare

Wishing you the beauty, blessings and joy this season brings 🌴

I am looking forward to my final year of teaching in 2026. What a wonderful journey it has been for me. So many blessings, including meeting many of you, along the way. And now, it’s my final tour.

Exceptional live in-person learning opportunities in Long Beach CA, San Antonio TX, Fremont CA and Dallas TX 🌴

Sign up for my blog on my website to receive notification when my finalized seminar schedule posts in January 2026.

Join me, and your colleagues to advance your clinical reasoning and problem-solving complex patients,  from fragile neonates through school-aged children.  An experience, I promise, you won’t forget.

The highlight for me will be the conversation with you. It happens between PowerPoint slides, at lunch, and on breaks. The “ah-ha” moments and new ideas generated from colleagues or new perspectives that may change our practice. Discussing new approaches and the “why” that just makes sense. Making connections with professional colleagues face to face and remembering……we are all in this together…🌴

All the best in this New Year ahead! I hope to see you one last time in 2026 🌴🌴

With gratitude~

Catherine

 

Happy Thanksgiving 2025 from Catherine Shaker

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                 This Thanksgiving, I am grateful for the opportunity to learn along with you and share our common passion…  safe and successful feeding.                                                  Supporting the feeding relationship for infants, children, and their families is at the heart of what we do, and I’m thankful for the chance to be  part of your journey and theirs…
                                  May your holiday season be filled with joy, love,                                  and moments that matter most.
With gratitude~   …… Catherine

Catherine Shaker Seminars: Wrapping Up 2025 Texas Style! 🌟

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During 2025, I traveled from the heartland to the West coast and met (and re-connected with!) some amazing people along the way. Last stop: Houston! Here are some of my new forever friends that I met in Houston…..🎈🎈🎈

From past colleagues who joined me in Plano, to the dedicated team at Memorial Hermann Children’s Hospital in Houston who learned along with me for 7 days, to the dynamic team in Lexington, to the inpatient/outpatient team at Miller Children’s in Long Beach,  to the Walnut Creek CA Rehab leader and her rehab team who made me feel welcome for 7 days of teaching, to the amazing team at Nationwide Children’s, one of the top US children’s hospitals and one of the largest rehab teams in the country 🌷🌷🌷

From all coasts and around the world (Canada, Dubai, Spain, Japan, Australia, and the UK), over 600 therapists joined me to share our common passion for neonatal/pediatric feeding and swallowing. So many remarked about the gift of being in the same room, networking and enjoying higher-level conversations with each other and the group. From deep dives across multiple components of assessment and intervention, to practical solutions and case problem-solving, to considering the impact of the current research on our practice and, most reinforcing, navigating the practice challenges each of us faces daily. We each left feeling renewed knowing we are all in this together. And lifelong learners 🧠🧠🧠

I am looking forward to my final year of teaching in 2026. What a journey it has been. So many blessings along the way 💟💟💟

Sign up for my blog on my website to receive a notification when my 2026 Seminar schedule is posted. It will take me to the heartland and the Western US.

I hope to learn along with you in 2026~🌺🌺🌺

Catherine

Some of my favorite comments over the year: 

“Catherine is a wealth if knowledge, kind and respectful to participants. I loved the plethora of research articles I now have ready to share with staff. The videos, sample documentation notes, resources provided, the real-world application of learned material and, most of all,  her  guiding us through critical thinking, was all invaluable.” Brianna, SLP

“Very positive learning experience! A lot of areas discussed within a two-day span but in an organized and well-presented way. Catherine has a lot of knowledge AND knows how to teach it!”  Kelsey, OTR

“Loved the case studies and open discussion that was welcomed. It allowed for collaboration and critical thinking. Considered a variety of areas to make a well-rounded clinician in feeding/swallowing. Provided guidance with evaluating how whole systems impact feeding/swallowing function. Celine, SLP

“ Catherine is a phenomenal instructor with a clam demeanor, and a great speaking cadence that allows for questions and interaction. Such a wonderful combination of clinical experience, clear critical thinking and thoughtful feedback.” Heather, OTR

“As an  adult SLP transitioning to peds dysphagia, I have gained so much knowledge about the Pedi world. I am ready to apply my newly learned skills and become more hands on with the pediatric population.” Trayonna, SLP

“I have been waiting for an advanced course where we could all interact and learn from each other. I finally found it. I might even come again next year and participate with a different group. Such great problem-solving about so many different types of pediatric patients. Thank you! Veronica, SLP

 “Thanks for being such a spark to help me keep learning! I learned more in two hours than I did in four days at a different conference. Thanks too for your willingness to both objectively discuss and answer questions about things with which you both agree with and disagree.” Emma, SLP

 “I came away with so many strategies and a better understanding of what to look for when working with a child. Really helped me look at the whole picture”. Priscilla, OTR

 “Your course is a huge bang for my buck! Honestly invaluable. Your real-life experiences helped apply the research and knowledge you shared. And for referencing so many other excellent professionals working in the field. Really filled in the blanks for me”. Kerry, SLP

“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

Final 2025 Offering: Catherine Shaker Seminars Coming to Houston

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Join me in Houston  for a learning event that will change your practice~ 

OTs, SLPs and PTs welcome….

  • Pediatric Swallowing and Feeding: The Essentials –  Oct 13-14
  • Pediatric Video Swallow Studies: From Physiology to Analysis –  Oct 17
  • Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Issues –  Oct 15-16
  • NICU Swallowing and Feeding: In the Nursery and After Discharge in EI  – Oct 18-19

Most importantly, I bring my passion for feeding and swallowing to every course I teach. Its my promise to you….

Click here for Catherine Shaker Seminars 2025 Brochure

Click here for Site/Location Info

 

Catherine’s Research Corner: Comparative Analysis of Pharmacological Treatments and Lifestyle Modifications for Managing Gastroesophageal Reflux Disease in Infants: A Literature Review

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Just published in The British Journal of Medicine. This is a quick read with key considerations that inform our practice with infants who present with GERD, and help us speak from a perspective of knowledge.

Mirani, Y., Roy, Y. J., & John, T. (2025). Comparative Analysis of Pharmacological Treatments and Lifestyle Modifications for Managing Gastroesophageal Reflux Disease in Infants: A Literature Review. British Journal of Hospital Medicine, 1-10. Available open source on Google Scholar.

Abstract
Gastroesophageal reflux disease (GERD) is a common condition in infants, causing vomiting, irritability, and feeding difficulties. Though typically mild and self-limiting, severe cases may result in complications such as esophagitis, failure to thrive, or recurrent aspiration pneumonia. This review highlights a tiered approach to management, emphasizing non-pharmacological methods such as feeding adjustments, and thickened feeds as first-line treatments. These strategies are effective for mild to moderate
cases, reducing unnecessary medication risks. Pharmacologic interventions, primarily proton pump inhibitors and histamine-2 receptor antagonists, are reserved for severe cases, such as erosive esophagitis or persistent respiratory symptoms, where non-pharmacological approaches have failed. While medications promote mucosal healing, their efficacy for symptoms like irritability or vomiting in non-severe cases is mixed, raising concerns about overuse. Adverse effects include increased infection risks, gut
microbiota changes, and nutrient malabsorption. Future research should refine diagnostic criteria and develop evidence-based guidelines to prevent overtreatment.

Catherine Shaker’s Walnut Creek CA Seminars…A Memorable Moment! for All

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Just returned from teaching in Walnut Creek, California for seven days! What a beautiful part of the West Coast. Over 160 engaged and passionate rehab professionals (SLPs, OTs and PT’s, and wonderful NICU nurses) joined me for this practice-changing event.

  • a conference center full of clinical wisdom and intellectual curiosity
  • deep dives about the latest research
  • critical thinking about our common clinical and professional challenges
  • actively problem-solving complex clinical presentations
  • and a sense of renewal … new lasting friendships ignited….

Here I am with some of the dedicated Neonatal Therapists and Nurses on the last day, celebrating each other, being lifelong learners, and the common thread…our passion for feeding and swallowing….and for the children and families who trust their care to us! 

Join me in Plano, Texas (September) or Houston, Texas (October). I promise you a learning experience that you will always remember!

Click here for Catherine Shaker Seminars 2025 Brochure

Click here for Site/Location Info

 

 

Catherine’s Research Corner: Current Trends in Oral Feeding of NICU Infants

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Htun, Z.T., Ferrara-Gonzalez, L et al (2025)  Oral Feeding of NICU Infants: A Global Survey of Current Practices and the Potential of Cold Milk Feeding Intervention. Nutrients                         -> available open access on Google Scholar

Summary of key takeaways:

A cross-sectional global electronic survey of 32 institutions across the US was distributed via professional society listservs and closed online professional group forums targeting neonatal providers and feeding therapists from June 2023 to June 2024. A total of 210 complete responses were received from level IV (51%), level III (42%), and level II (5%) NICUs.

The objectives of this study were to (1) Evaluate the prevalence of cold milk feeding as a therapeutic strategy for managing dysphagia in hospitalized infants. (2) Identify the PMA at which oral feeding is typically initiated for those born preterm. (3) Investigate the types of noninvasive respiratory support, such as CPAP and HFNC, that are permitted during oral feeding in hospitalized infants.

Results:

(1) While 30% of the respondents were aware of cold milk feeding as a dysphagia intervention, only 15% of the total respondents reported using it in practice. Among the 32 institutions implementing cold milk practices, only one had an established protocol.

(2) PMA at start of PO:

— data suggests 33-34 weeks PMA remains common (36% reported initiating oral feeds at or before 33 weeks’ , 43% at 34 weeks, and 9% at 35 weeks)

— data showed 70% indicated that feeding readiness cues were used alongside PMA

(2) Feeding protocols for their NICUs: 72% reported having a feeding protocol in place, often incorporating cue-based tools.

(3) Feeding on respiratory support: Most respondents (87.5%) did not allow oral feeding on CPAP, whereas 78% permitted PO on HFNC support (majority required ≤2L)

Conclusions: Although the awareness of cold milk feeding in neonates is increasing, its implementation remains limited and lacks standardization. Significant variability exists in oral feeding practices, particularly regarding feeding during respiratory support. This underscores the need for further research and evidence-based guidelines to ensure safe and consistent care for preterm infants.

Join me at one of my courses soon for the latest evidence-base pertinent to YOUR practice site, whether home care, hospital, community outpatient/early intervention, school-aged children or the NICU…

 

Catherine Shaker Seminars: A Practice Changing Event in Columbus!

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I just returned from an invited presentation for four days at Nationwide Children’s Hospital in Columbus, OH. America’s third largest children’s hospital, Nationwide Children’s last year had nearly 1.8 million patient visits from all 50 states and 45 countries.  It is ranked among the top 10 NIH-funded freestanding pediatric research facilities in the U.S.  My passion for lifelong learning and evidence-based care in feeding and swallowing felt right at home in this remarkable setting.

Nearly 100 SLP’s and OTs from across the US and as far away as Seoul, South Korea and Saipan (near Australia) came to learn along with me.

Here I am with Minjung Kim, OT,  National  University Hospital, Seoul, South Korea, an international scholar who joined us.

Such experience and brain power in one room! We enjoyed deep dives into complex comorbidities, problem solving our complex patients, from neonates and babies to school aged children with ARFID who always find a place in our hearts. Our collective wisdom helped us consider hot topics like the latest guidelines on thickening, clinical weaning, swallow studies and challenging  communication “opportunities” with our medical colleagues. Despite different settings (from NICU to Home Health to Outpatient, EI,  to acute care ……our shared struggles, clinical questions and day to day clinical challenges provided a common ground for practice-changing conversations.

Make plans to join me at one of my last three remaining locations. I promise you a learning experience you won’t forget…..

Click here for Catherine Shaker Seminars 2025 Brochure

Click here for Site/Location Info

Calling All Pediatric Therapists: Catherine Shaker Seminars Coming to NE and SE Texas!

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Its a first for me! I will be coming to both Plano and Houston …in 2025!

Join me in Plano (September) or in Houston (October)  for a learning event that will change your practice~

OTs, SLPs and PTs welcome….

Both locations will offer:

  • Pediatric Swallowing and Feeding: The Essentials –  Sept 8-9, Oct 13-14
  • Pediatric Video Swallow Studies: From Physiology to Analysis –  Sept 10, Oct 17
  • Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Issues –  Sept 11-12,  Oct 15-16

and an added bonus in Houston:

  • NICU Swallowing and Feeding: In the Nursery and After Discharge in EI  – Oct 18-19

In my NICU Seminar we discuss the latest research, state of the art assessment/treatment strategies for complex sick newborns and preterms with swallowing feeding challenges, trachs, tubes, readiness for PO, CPAP/HFNC, considerations for VFSS. Problem-solve practice and professional issues, navigating your role in the NICU, difficult conversations with the team, and complex feeding issues and diagnoses unique to this population. I infuse my course with my real-life experiences in a large 160 bed Level IV.

Most importantly, I bring my passion for feeding and swallowing to every course I teach. Its my promise to you….

Problem-solving with Catherine: Pediatric Dysphagia Screening Tool

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QUESTION: What swallow screen are your hospitals using, (specifically for the RNs to use either on admission or with change of status). We are an adult hospital with a large Women’s and Children’s center with a recently upgraded Trauma status. We have a dedicated Peds ED and we want to do better at capturing all the patients who need swallow evaluations by SLP. We get a great variety of orders on a consult basis, but physicians don’t always catch every risk factor of course or know how a patient does in every skill. Our adult side uses the Yale Swallow Screen but we know that is not standardized for Pediatric patients.

CATHERINE’S ANSWER: 

The Pediatric Screening-Priority Evaluation Dysphagia (PS-PED). It gives a pilot of potential considerations for screening protocol and YES/NO prompts that may help identify higher risk populations based on clinical history, health status and feeding conditions.

Cerchiari, A., Tofani, M., Giordani, C., Franceschetti, S., Capuano, E., Pizza, F., … & Biondo, G. (2023). Development and Pilot Study of a Pediatric Screening for Feeding and Swallowing Disorders in Infants and Children: The Pediatric Screening–Priority Evaluation Dysphagia (PS–PED). Children, 10(4), 638.

I like the PS–PED for both ED and acute care pediatric patients. It looks at predictive markers related to high risk co-morbidities (neuro, cardiac, GI, respiratory), current health status (ETT, alertness, growth/malnutrition, recurrent RTIs, need for suction, GERD, constipation, NG/GT) and feeding conditions (parenteral /enteral nutrition, atypical diet for age, prolonged mealtimes). 14 yes/no items. Can be administered in less than 10 min and does not require any specific education in swallowing disorders. Pediatric nurses report it is easy to use. Does not involve administering any food to the patient. And what I really like too is data was collected for 4 month old through 17 y/os and that the psychometric properties strongly highlight solid reliability and support the screening tool’s usability.

It should work well in your Peds ED. Could also be used as a tool to enhance appropriate referrals in PICU – current research shows that “SLP involvement is infrequent in US PICUs. PICU teams should be educated about the scope of SLP practice, to support communication and oral feeding needs during early recovery from critical illness.”

Santiago, R., et al (2024). Speech-language pathologist involvement in the pediatric intensive care unit. International journal of speech-language pathology, 26(5), 674-681.

I suspect the PS-PED could be easily integrated into the electronic medical record for ease of use across multiple disciplines

 

Problem-Solving with Catherine: Weaning Respiratory Support during the Aerobic Demands of Feeding in the NICU?

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QUESTION: Does your unit use a protocol similar to the one in this article (dropping kids who are typically on 3-4L to 2L to feed). If so do you have any thoughts or feedback?

Yildiz Atar, H., Ryan, R. M., Ricciardi, S., Nauman, C., Pihlblad, M., Forsythe, T., & Bhola, M. (2024). Introduction of oral feeding in premature infants on high flow nasal cannula in a level IV neonatal intensive care unit: a quality improvement initiative. Journal of Perinatology, 1-8.

https://pubmed.ncbi.nlm.nih.gov/38714842/

CATHERINE’S ANSWER:  I am not aware of any other similar published protocols with a wean of respiratory support. The NICU OT at Rainbow Babies Level IV who co-authored, Sheri Ricciardi, is thoughtful. When I spoke with her about the protocol and its development, the careful infusion of a sound therapeutic perspective into the operationalizing of the protocol every step of the way is evident and sets it apart in my mind. The article describes this  as a “very safety-focused protocol”, which has not been stated in previous published protocols I recall reading regarding PO feeding on CPAP and/or HFNC.

That said, I think the “wean” during PO to less respiratory support seems to come only from the “informal” guideline in many NICUs to “PO at no greater than 2 LPM support” without other evidence-based rationale. It seems to me counterintuitive that the infant can indeed be weaned during the aerobic demands of PO feeding to less respiratory support than “required” at baseline…… from a cardiopulmonary perspective, given that these are often our most fragile infants with CLD, that doesn’t make sense.

Is the level of tolerance by the “weaned” infant subject to less restrictive parameters? Often the monitors don’t tell the whole story during PO feeding, and our infants can ride under the radar. How often we see in radiology they infant continues to suck and swallow despite the trachea invaded by barium, in the absence of an A/B/D.

Given that some well-intentioned caregivers may respond in the NICU to our worry about WOB during PO by remarking “oh that’s how he always breathes, keep feeding”…when in actuality the “cost” of the wean to the infant may be more significant than might be apparent..? Subtle increases in WOB, subtle changes in engagement, change in motor control that may be subtle, need for more resting, slight delays in swallow initiation and/or airway closing or re-opening surrounding the swallow—these data points matter.

I wonder what a pulmonologist would say about the increased physiologic burden with the wean and the implications for function at a physiologic level, even at the level of the alveoli. Just thinking out loud.

If we have no objective data about the impact of the wean on swallowing physiology, we are basing our impressions on clinical data only. Yet these are are most fragile feeders who are the ones for whom we most often need a VFSS. Data from Duncan et al 2018 (out of Boston Children’s) reinforced that clinical impressions about airway protection have poor sensitivity. I worry for these fragile little ones for whom the noble and well-intentioned goals of PO feeding and getting home may not be without their own attendant sequalae for the infant. All of the answers are not in and in the interim we must proceed with caution on behalf of our little ones.

Neuroprotection is best supported with a focus on the “continuum” , which starts with individualized feeding readiness intervention. We follow our infants once stable on nCPAP, each with an individualized plan along this continuum. As Bobbi Gittens Pineda, OTR has said “vulnerability of infants in the real world context must be carefully evaluated” when we plan our interventions. A wonderful relevant reference is the publication by our colleague Rachel Scandiffio Selman OTR (2025). An on going encumbrance is that for some well-intentioned Neos, there may not even be a continuum that includes a period of pacifier dips in readiness to begin establishing the motor maps required. I suspect that is due, at least in part, to a lack of full appreciation for the complex underpinnings required for PO feeding and the abundant research that correlates co-morbidities with PO feeding difficulties and profiles infants at highest risk.

 

Catherine’s Research Corner: Cerebellar Development and the Burden of Prematurity… and Beyond!

Catherine Shaker Seminars Leave a comment

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 form 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.