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………………..

Na, Y., Choi, J., Choi, J., Oh, S. M., Jang, H., Choi, S., … & Kwon, J. Y. (2025). Videofluoroscopic swallowing study predicts clinical outcomes in critically Ill children with dysphagia: a retrospective observational study. Frontiers in Pediatrics, 13, 1507645.

Whether you evaluate and treat children in the community who may be post-hospitalization in PICU, or you work in pediatric  acute, this study will inform your practice. It provides valuable contributions to our current knowledge base by highlighting the patterns of dysphagia in critically ill children who return to community care post-hospitalization. It also highlights the predictive value of VFSS in identifying silent aspiration, and in predicting significant patient outcomes, such as the length of stay in PICU and delays in initiating oral feeding. These insights are crucial for improving the quality of care for these vulnerable children while inpatient, and after discharge home to community therapy.

QUOTE: It provides significant insights into the prevalence and implications of silent aspiration in children within the PICU setting, presenting detailed findings from VFSS. The most significant predictors of silent aspiration are age, laryngeal cleft, laryngomalacia, unilateral vocal fold paralysis, developmental delay, epilepsy/seizures, syndromes, and cardiac disease, which are common diagnoses in children in PICU. Our research builds on these findings, identifying intubation duration and the act of intubation itself as significant  predictors of aspiration risk. silent aspiration predicted a longer PICU LOS and poor oral feeding outcomes at hospital discharge. This finding not only aligns with but also builds upon the findings of da Silva et al, who reported extended hospital and PICU stays and delayed oral feeding in children with dysphagia. Our research underscores the critical role of early detection and intervention in managing dysphagia within the PICU. Early identification of silent aspiration through VFSS can facilitate and timely therapeutic interventions, potentially reducing the PICU length of stay and improving oral feeding outcomes at discharge.

Dysphagia in the PICU often increases hospitalization length and remains unresolved until discharge or beyond. By addressing swallowing difficulties early and implementing appropriate interventions, there is a possibility of reducing complications associated with aspiration, potentially leading to shorter PICU stays (and return to home and community followup) . Our study broadens the scope by including patients beyond those with PED (Post Extubation Dysphagia) , offering a more comprehensive view of dysphagia in pediatric critical care. Given that longer intubation periods and delayed VFSS evaluations were associated with prolonged PICU stays, it would be advisable for physicians to consider developing a protocol for performing a dysphagia work-up if intubation is prolonged.

ABSTRACT:

Background: This retrospective observational study aimed to investigate the features of acute dysphagia observed during videofluoroscopic swallowing study (VFSS) in critically ill children and their potential to anticipate clinical outcomes.

Methods: Administrative healthcare data of children aged 1–18 were analyzed. Data were collected from the pediatric intensive care unit (PICU) of a single tertiary medical center in South Korea between March 2019 and December 2022.We reviewed VFSS conducted on patients in the PICU who were referred by clinicians suspecting dysphagia.

Results: A total of 36 children were included in the study; 52.8% exhibited aspiration on VFSS. In this investigation, participants were provided with pureed food, liquids, solids, and a combination of solids and liquids (referred to as mixed) during the examination. Any occurrence of aspiration throughout the examination was deemed as aspiration. All individuals displaying aspiration were found to have silent aspiration. Silent aspiration was associated with a longer length of stay (LOS) in the PICU. Logistic regression analysis revealed that the time from PICU admission to VFSS and intubation duration significantly influenced LOS. Abnormal findings in the VFSS, including aspiration, delayed swallowing reflex, insufficient laryngeal closure, and residue, were statistically significant variables in determining the feeding mode at discharge.

Conclusion: This study highlights the importance of VFSS in assessing swallowing function in critically ill children. It suggests that VFSS findings, such as silent aspiration, can aid in predicting patient outcomes, including LOS and the delay in oral feeding.

Brinker K, Winn L, Woodbury AE, et al. (2025) The nutrition profile and utility of banana puree as a liquid thickener for medically complex infants with dysphagia. Nutr Clin Practice  40:227‐238

There is limited but growing evidence to support using banana puree for infants <12 months of age. Efficacy, nutritional value, and safety are key issues. Among all purees tested, banana puree has achieved the greatest thickness level and maintained that same level of thickness regardless of temperature overtime. (Brooks et al 2024, Brooks et al 2022). Thickening with bananas can allow infants with swallowing difficulties to experience  oral feeding, and can facilitate positive feeding experiences, without direct evidence of compromising safety. Banana puree has an appealing taste,  and may offer a more cost‐effective option for families than commercially branded products.

This paper is unique in that its authors reflect the team—an SLP, PT, MDs and a also a registered dietician. It addresses: Involving the physician (attending or pediatrician) in decisions about thickeners and the role of a dietician; and  the importance of the nutritional impact of banana puree. It informs our problem-solving, with the team,  about whether banana puree is the optimal thickener  for our infant patients who require thickened feedings for dysphagia. The authors also remind us as well about the critical role of  data via a VFSS to objectify swallowing physiology and the impact of thickeners, selected utensils and combine interventions. Enjoy this new addition to our evidence base. We are grateful to our SLP colleagues, co-authors Kristin Brinker and Michelle Taggart!

Here is quoted commentary from the paper. You can find the full text through open access on Google Scholar.

Nutrition is an important consideration when choosing the right thickening agent because

it may disrupt the delivery of nutrients to infants. Thickening agents can displace the

nutrition content in formula and human milk, potentially impacting feeding osmolarity,

gastrointestinal transit time, bowel movement frequency, stool consistency, and nutrient

absorption. Banana contributes carbohydrate calories without the comprehensive nutrition

density, essential vitamins, and minerals inherent in human milk and formula. Improper or

excessive use of banana puree can result in weight gain without the requisite accumulation

of vital vitamins, protein, and minerals necessary for optimal bone mineral density and lean

muscle mass gain. Fruit puree lacks essential fatty acids for optimal brain and eye

development. Introducing solid foods before four months of age  has been associated with

heightened risks of obesity, diabetes, eczema, and celiac disease. Because bananas

have a high potassium content, cautious deliberation is warranted, especially for infants

with renal disease. If renal function or potassium clearance is a concern, banana puree as

a thickening agent may not be suitable. Restricting the total banana volume to 15% of feeds

enables balanced delivery of nutrition, including essential fat and protein, mitigates

the risk of hyperkalemia, and increases likelihood of favorable gastrointestinal tolerance

without significant constipation effects. Although using up to 15% bananas

slightly exceeds potassium recommendations when fortifying formulas in some cases we

continue to recommend this limit unless infants have renal dysfunction or difficulty with

potassium clearance. This allows for optimization of both nutrition and hydration

needs in these infants. Our institution did follow the infants exposed to banana puree as

thickener, and our preliminary findings did not show that infants on banana puree

thickener had more complications than those on Gelmix (Finch et al., manuscript in

preparation). However, growth, laboratory results, and clinical presentation

should guide decision‐making for individual patients.

Managing infants with dysphagia requires a multidisciplinary team. As mentioned above, a

pediatric registered dietitian should be involved in nutrient analysis and monitoring growth

over time. Additionally, the SLP should provide ongoing assessment and work towards

safely discontinuing thickening agents as soon as possible. The SLP can guide feeding

position and bottle nipple selection. The flow rate of a bottle nipple contributes to the

infant’s ability to feed by mouth safely and efficiently and must be considered carefully

when using thickened milk. Most studies conducted to measure flow rates of various bottle

nipples have shown average flow rates using unthickened formula. They should not be

generalized with the use of thickened liquids. A recent study by Pados et al conducted flow

rate tests for seven different Dr Brown nipple types using thin (IDDSI Level 0), slightly thick

(IDDSI Level 1), and mildly thick (IDDSI Level 2) infant formula. These bottle nipple flow

rates tested with thickened liquids may be used to guide clinician decisions. However,

when making nipple recommendations, one must also consider other factors

that contribute to the safety and efficiency of oral feeding, including medical complexity,

oral‐motor control, and the infant’s integration of respiratory coordination. The use

and recommendation for thickened liquids should only be made after objective evaluation

via VFSS or fiberoptic endoscopic evaluation of swallowing providing an individualized

assessment of the infant’s response to varying nipple flow rates using various

consistencies. Feeding practice recommendations should be comprehensive,

including the appropriate level of thickened milk, bottle nipple, and all necessary feeding

interventions such as positioning and co-regulated external pacing.  Gastroenterologists

should also monitor gastrointestinal complications and other medical or surgical

interventions if the infant is not progressing as anticipated with thickened feeds.

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.

Question:

I am looking for information regarding how oral care is performed with infants who are no longer being provided with breast milk (donor or MOM) which in our Level III NICU is usually after 34 weeks PMA if no longer available from mother AND not yet PO feeding.  I’ve seen some facilities using sterile water and some even formula via oral swab, but looking to see what is happening out there!  Thanks.

Catherine’s Answer:

NICUs typically have policies and procedures specific to oral care administration that the nursing team follows because application to the inside of NICU infants’ mouth as oral care is considered immune therapy. Colostrum and early MOM or DBM are high in immunologic, anti-infective and anti-inflammatory factors. And we recognize, as therapists, its potential benefit for the neonate’s oral-sensory processing. Its sweet taste can provide a positive oral experience and perhaps entertain early learning; some researchers wonder if, when it is offered in a developmentally supportive way, the experiences may support sensory-motor learning, and the laying down of pathways in the brain to be recruited later.

There are options built into the P & P’s to accommodate infants who are intubated or have co-morbidities that require an adjusted pathway, and typically that also includes approved optional fluids for that NICU. When no MOM or DBM is available, some protocols I have seen then utilize sterile water. It, however, lacks the immunologic, anti-infective and anti-inflammatory properties of MOM or DBM, and has no “sensory load” for the oral-sensory environment, but neonatologists have cited its sterile nature as a benefit which is part of the “risk-benefit” paradigm that is understandably paramount in the NICU.

Perhaps talk with your neonatal nursing and neonatology colleagues in your NICU — their experience and clinical wisdom is amazing I have found—-and do a lit search — there is so much out there — to gather information you are seeking. Utilize this as an opportunity for cross-fertilization of knowledge about oral cares, partnering for a more developmentally-supportive approach if that might be an opportunity, and further-building of those relationships in your NICU that, as you know, create an amazing environment in which we can be lifelong learners.

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

I look forward in 2025 to bringing you exceptional live in-person learning opportunities in Columbus OH, Dallas TX, Houston TX, and California. Other sites in the southeastern US and the Midwest are in the works. Sign up for my blog on my website to receive notification when my finalized seminar schedule posts in January 2025.

Join me, and your colleagues to advance your clinical reasoning and problem-solving complex patients,  from fragile neonates through school-age.

…..The real voyage of discovery consists not only in seeking new landscapes, but also
in looking thorough new eyes……

All the best in 2025!

Catherine