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

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.

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…

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

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….

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

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.

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.

Thickening for dysphagia is so complex. We try to avoid thickening whenever possible, and consider it as our last resort for intervention, no matter the age of our patient… infant, child or adolescent.

Research can seem conflicting. Time to thicken is critical for thickening agents even those used somewhat routinely. That’s why I focus on the latest and most valuable research data in all my courses, so we can thoughtfully problem-solving for our complex patients.

This just-published article adds to our evidence base about using anti-regurgitation formulas as thickeners.

Tommelein, E., Baert, K., Ombecq, M. et al. Anti-regurgitation infant formulas and antacid medication: match or mismatch?. Eur J Pediatr 184, 336 (2025). 

Key Takeaways:

• Commercially available infant formula sometimes uses thickening agents to reduce regurgitation, but their effectiveness may vary depending on composition and gastric conditions.
• Some thickening agents require an acidic environment to activate, which may be compromised by concurrent use of gastric acid suppressants.
• Viscosity in some formulas changes over time, indicating that preparation timing affects therapeutic consistency

The full abstract is available on Google Scholar.

I always say…..there is no cookbook for pediatric swallow studies; cookbooks were made for cooking, not for instrumental assessments. Knowing potential interventions, but also what interventions would be contraindicated based on pathophysiology/history/co-morbidities is only the starting point. What we then recommend may indeed tip that balance between risk-benefit, and in either direction. Optimizing the risk-benefit ratio for the infant/child requires us to utilize critical reflective thinking, with a focus on the nature of the pathophysiology, the biomechanical alteration/impairment, and its implications for that unique infant/child. In drilling down to that infant’s/child’s “story”, we then realize that a plan for patient A with the same objective data from radiology may not be appropriate for patient B.

The nature of the pathophysiology in the neonatal/pediatric population has nuances that reflect the dynamic interaction of the developmental trajectory of motor learning with evolution of the swallow. Superimposed on this, then, are the co-morbidities that increase risk, especially prematurity, CLD, CHD and other diagnoses that adversely affect cardio-respiratory integrity.

The evidence-base in the literature to guide us is emerging and is still in its infancy. Laryngeal Penetration (LP) has been associated with negative clinical outcomes in subsets of the pediatric population, including increased risk for PNA and aspiration (Gurberg et al, 2015). Duncan et al (2020) out of Boston Children s Hospital found in their study that laryngeal penetration is not transient in children < 2 years of age and may be indicative of aspiration risk. In their study, on repeat VFSS: 26% with prior LP had frank aspiration. The authors remarked that “Any finding of LP in a symptomatic child should be considered clinically significant and a change in management should be considered”. That may be a change in position, change in nipple, change in cup, adding a control valve, limiting bolus size, pacing, slow rate of intake, smaller sips, not necessarily thickening.

Take a look at another recent addition to our guiding evidence-base…

Miller, A. L., Miller, C. K., Fei, L., et al (2024). Predictive value of laryngeal penetration to aspiration in a cohort of pediatric patients. Dysphagia, 39(1), 33-42. Abstract

Abstract

Videofluoroscopic swallow studies (VFSS) provide dynamic assessment of the phases of swallowing under fluoroscopic visualization and allow for identification of abnormalities in the process, such as laryngeal penetration and aspiration. While penetration and aspiration both reflect degrees of swallowing dysfunction, the predictive potential of penetration for subsequent aspiration is not fully elucidated in the pediatric population. As a result, management strategies for penetration vary widely. Some providers may interpret any depth or frequency of penetration as a proxy for aspiration and implement various therapeutic interventions (e.g., modification of liquid viscosity) to eliminate penetration episodes. Some may recommend enteral feeding given the presumed risk of aspiration with penetration, even when aspiration is not identified during the study. In contrast, other providers may advise continued oral feeding without modification even when some degree of laryngeal penetration is identified. We hypothesized that the depth of penetration is associated with the likelihood of aspiration. Identification of predictive factors for aspiration following laryngeal penetration events has significant implications for selection of appropriate interventions. We performed a retrospective cross-sectional analysis of a random sample of 97 patients who underwent VFSS in a single tertiary care center over a 6-month period. Demographic variables including primary diagnosis and comorbidities were analyzed. We examined the association between aspiration and degrees of laryngeal penetration (presence or absence, depth, frequency) across diagnostic categories. Infrequent and shallow penetration events of any type of viscosity were less likely to be associated with aspiration event(s) during the same clinical encounter regardless of diagnosis. In contrast, children with consistent deep penetration of thickened liquids invariably demonstrated aspiration during the same study. Our findings show that shallow, intermittent laryngeal penetration of any viscosity type on VFSS was not consistent with clinical aspiration. These results provide further evidence that penetration-aspiration is not a uniform clinical entity and that nuanced interpretation of videofluoroscopic swallowing findings is necessary to guide appropriate therapeutic interventions.

Reference:

Duncan, D. R., Larson, K., Davidson, K., May, K., Rahbar, R., & Rosen, R. L. (2020).Feeding interventions are associated with improved outcomes in children with laryngeal penetration. Journal of pediatric gastroenterology and nutrition, 68(2), 218.

Good news for our OT colleagues!

The Ohio State Board of Occupational Therapy has approved both of my Columbus OH seminars for CEUs. The approval codes will be indicated on the certificate of attendance provided at the conclusion of each seminar

• Pediatric Swallowing and Feeding: The Essentials July 15-16
• Advanced Infant/pediatric Dysphagia July 17-18

For OTs and PTs in other states:   

Texas Seminars: The Texas OT Practice Act and Rules allow for offerings that are not pre-approved to be used for license renewal. This page (click) provides some context. Because the TSBOTE allows the licensee to determine if an offering meets the criteria for an acceptable activity, the course certificate is enough for the licensee to use when applying for license renewal.

CABOT (The California State Board of Occupational Therapy): All Shaker seminars are approved by CABOT for advanced practice certification in swallowing.

State Boards of Occupational and Physical Therapy typically accept contact hours earned through seminars provided by Pediatric Resources. Pre-approval of courses has not typically been required. Check with your State Board. Maintain a copy of your certificate of attendance, the brochure (which states goals and objectives and contact hours awarded).

If you need any further supporting documentation when submitting contact hours, please email us at pediatricseminars@gmail.com.

Take a look at this recently published paper which is available Open Source:

Puri, N. B., & Sanchez, R. E. (2025). Gastroesophageal Reflux in Children. Current Treatment Options in Pediatrics, 11(1), 10. https://doi.org/10.1007/s40746-024-00321-5

The authors are well-respected and are part of the medical team at Nationwide Children’s Hospital. They discuss a medical perspective on typical pathophysiology, GER symptoms, Red Flag Symptoms and differential diagnosis in infants and children/adolescents which can inform our practice as pediatric SLPs. The information is adapted from and consistent with ESPGHAN/NASPGHAN GERD guidelines. They remind us that currently, there is not a single diagnostic test for the diagnosis of GER, and discuss the current testing considered in patients with GER and technology that hopes to advance their care and diagnostics. Finally, they address current approaches to medical management that we must be aware of when working with our medical colleagues.

Being familiar with this information can help us speak from a perspective of knowledge, whether interacting with a neonatologist, a pediatrician or an intensivist or a GI doctor. We can then respectfully advocate regarding our added and valuable therapeutic perspective that considers the whole child, sensory, volume/intake issues, day to day realities, and the interventions that the medical perspective has not yet fully embraced, sadly.

Catherine

A recent post on social media asked…..

“Has anyone been to Catherine Shaker’s seminars?

They will be in my area so I can do an in-person course.

Do you recommend?”

These are some of the responses~

• I highly recommend! I took her Advanced pediatric feeding course about 10 years ago. It was phenomenal. Catherine is a gifted teacher who has worked for decades, is a true specialist and expert clinician and has a kind spirit. She models so well how to think about clinical diagnostics, how to collaborate and with gentleness and compassion for the families. I learn something new every time she responds to questions in our FB group.
• Yes! Her course was my first feeding course and was wonderful!
• Well worth the $$!
• Yes! Her courses were foundational for me! She’s amazing
• Yes! Don’t miss it! She is a wealth of information and a talented speaker
• YES! They are wonderful courses.
• 100% recommend
• Excellent
• So good! Catherine Shaker is such a wonderful wealth of knowledge. Highly recommended!
• I went to one last Fall. Highly recommend!
• Highly recommended
• Yes! I gained so much confidence after her course.
• Went to all of them, LOVED them.
• Yes, and they are awesome!
• Wonderful courses and highly recommend.
• Yes! She’s wonderful!
• She’s excellent
• She is fabulous!

You can find years of feedback from my seminar attendees on my website under the “Testimonials” TAB via this link https://shaker4swallowingandfeeding.com/testimonials/

Click here for Catherine Shaker Seminars 2025 Brochure

Click here for Site/Location Info

……….See you in Lexington KY, Columbus OH, Walnut Creek CA, Long Beach CA, Plano TX, and Houston TX………………..