Catherine Shaker Seminars 2023: Real Time Clinical Problem-Solving

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

  • Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Issues
  • NICU Swallowing and Feeding: In the Nursery and After Discharge in EI
  • Pediatric Swallowing and Feeding: The Essentials
  • Pediatric Video Swallow Studies: From Physiology to Analysis
  • The Early Feeding Skills Assessment Tool: A Guide to Cue based Feeding in the NICU and 

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

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






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

hand puzzle


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

Catherine’s Answer:

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

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

pile of pacifiers ready for the pacifier fairyQuestion:

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

Catherine’s Answer:

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

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

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

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

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

I hope this is helpful.

Catherine Shaker Seminars: Take Your Practice to the Next Level!

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

How can dialectical thinking help you? | MHT

Join me for an exceptional learning opportunity!

  • Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Issues
  • NICU Swallowing and Feeding: In the Nursery and After Discharge in EI
  • Pediatric Swallowing and Feeding: The Essentials
  • Pediatric Video Swallow Studies: From Physiology to Analysis 
  • The Early Feeding Skills Assessment Tool: A Guide to Cue based Feeding in the NICU 

What your colleagues are saying….  ” It’s nice to know that even experienced therapists don’t have all the answers and need to problem solve and dialogue with others. I liked Catherine’s discussion “system-based thinking” when trying to differentially diagnose the reason why something might be happening. Loved the increased confidence this course gave me! It filled in lots of gaps.”  Violet, SLP


Catherine’s Research Corner: Congenital Heart Disease and Nutrition

Baby's Heart-lung System by Pixologicstudio/science Photo Library

For those of you working with infants with CHD, this is a great resource which includes a primer on CHD pathophysiology and nutrition needs. These infants are among our most fragile feeders, at risk for aversions and failure to thrive. The more we understand normal and altered structure/function of the heart, and the impact on nutritional needs and feeding, the more informed our clinical reasoning and our engagement with the team will be. So essential to supporting infants and families in both acute care and after discharge in early intervention. Here is the secure link from Nutricia Learning Centers:

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Catherine Shaker 2023 Seminars: New Baltimore Site and Cue-Based Offering for 2023

How to Improve Your Critical Thinking Skills and Make Better Business Decisions | Entrepreneur

Join your colleagues in Baltimore, MD in August for advanced clinical learning opportunities with Catherine Shaker and Dr. Suzanne Thoyre!

  • August 29-30: The Early Feeding Skills Assessment Tool (EFS): A Guide to Cue-Based Feeding in the NICU and EI
  • August 31: Pediatric Videofluoroscopic Swallow Studies: Physiology to Analysis
  • Sept 1-2: Advanced Infant/Pediatric Dysphagia: Problem-solving Complex Patients and Practice Challenges

In the Cue Based seminar, Dr Thoyre and I will guide the group in higher level conversations about complex feeding challenges in the NICU and after discharge, watching and scoring videos of neonates feeding and problem-solving next steps. In the Pediatric Swallow Studies seminar, discuss unique components of the swallow pathway across the pediatric age span, and then peel apart the pathophysiology and its implications.  In the Advanced Dysphagia seminar, focus on critical thinking for decision-making, problem-solving and interventions for our neonatal through school aged patients.  A great venue to share ways of navigating the practice challenges that each of us faces on a daily basis. Walk away feeling renewed. I hope to see you in 2023!


Problem-Solving with Catherine: Protocol driven clinical weaning of thickened liquids in pediatrics

Chart Label - Thickened Liquids

Question: Is there any current research on weaning protocols and the protocol for children with moderate to severe dysphagia and silent aspiration?

Catherine’s answer:

The team at Boston Children’s has provided us with a wealth of research to help inform our practice. This paper referenced below suggests a protocol for weaning thickened fluids via clinical data. Its implications are far reaching, and its recommendations require critical thinking.

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, I think, 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 SWP proceeds. Universal application of the SWP 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 pediatrics201, 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.

Perhaps more worrisome is the possible implication from the findings 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 and reflect, will always be the key.

I hope this is helpful.





Problem-Solving with Catherine: Adenoid Hypertrophy and Pediatric Dysphagia

Adenoid Hypertophy: What Is It, Causes, Symptoms, Diagnosis, Treatment ...


I am currently searching the literature on the impact of adenoid hypertrophy on pediatric dysphagia. I welcome, and appreciate any recent contributions to the field, ideally with objective findings from VFSS. Thank you in advance.

Catherine’s Answer:

Our ENTs tell me that they commonly see nasal congestion, mouth breathing and LPR (laryngopharyngeal reflux) in those infants/children who present with adenoid hypertrophy, and it often presents as tonsillaradenoid hypertrophy. It becomes most worrisome to them when it provokes OSA and/or chronic cough and there is associated clinical presentation of dysphagia. To their knowledge and mine, no one has published about this diagnosis related to objective data from VFSS but my impressions in radiology include nasopharyngeal narrowing, swallow-breathe incoordination leading to retrograde flow into the nasopharynx, which appeared due to the adverse effect of the obstructed nasal airflow on breathing, and, for 2 of them, incidental findings of LPR were witnessed during the VFSS. Post adenoidectomy follow-up VFSS results with infants who had isolated adenoid hypertrophy (without other co-morbidities) noted greater improvement in the integrity of swallowing physiology post-op than those with other associated co-morbidities (craniofacial anomalies, Down Syndrome, hypotonia).

I suspect the setting or “bigger picture” when there is tonsillaradenoid hypertrophy (or adenoid hypertrophy) is likely to be a critical factor for our index of suspicion, and for the nature of our radiological data. I also suspect that if the adenoid hypertrophy provoked significant mouth breathing, that could readily alter the anterior seal on the bolus, and there might also be a pathway for laryngeal airway invasion due the need for urgent breaths during dynamic swallowing. The co-occurring LPR might also lead to diminished laryngeal sensation which has been shown to be a risk factor for airway invasion as well. Partnership with ENT is so valuable at all ages for our pediatric patients, for optimal outcomes.





Problem-Solving: New infant referral but limited experience

Problem Solving Techniques in Artificial Intelligence (AI) -


I did infant feeding many, many years ago. Just got a referral for a 4-month-old, NG tube, congenital heart disease, some bottle feeding. What CE courses would get me up to date ASAP? Most of my feeding work in the past 10 years has been food avoidance and oral motor/chewing related difficulties in toddlers.

Catherine’s response:

It reflects your thoughtfulness that you reached out, as I suspect your instincts are telling you to think this through. Because our cardiac infants are some of our most fragile feeders. Given that her history and co-morbidities are likely complex, she will require some high-level problem-solving to keep her safe and to sort out all the pieces. Even after many years of complex infant feeding, I still have to pause and really think through these complex little ones. She is likely at high risk to invade her airway. Balancing the VFSS results, and her arduous course with family before you can be quite challenging for all of us. Before you accept referrals for infants with feeding problems, take the time to fully understand the underpinnings specific to congenital heart disease and its impacts on feeding and swallowing (and WOB and state regulation and postural control and neurodevelopment), as they will all need to be a part of your differential and plan. The infant-guided interventions for safe swallowing in infants, s/s that suggest a different plan, won’t be available to you right now. So, perhaps think about first building your guided/mentored experience with feeding/swallowing with more complex toddlers, then older more stable infants in EI and then increasing the complexity to younger and more complex infants. Taking courses under the gun isn’t the path to the critical thinking that is required with each population we serve, especially one so fragile. It would be no different if tomorrow I were asked to work in adult ICU at the very large medical center in which I work as a senior neonatal/pediatric swallowing specialist. I could technically treat adults in ICU because it is in our scope of practice as SLPs, but it would be ill-advised, unfair to the patient and family and likely place me in a potentially litigious situation should something adverse happen based on my recommendations or lack of insight, and clearly noted by an attorney or an expert witness from my limited preparation for that population. The risks all around would not be a good situation. If this (infant feeding/swallowing) is a direction you are passionate about, make a “long-term” (not “stop-gap”) plan (perhaps over 6 months rather intense and then an ongoing commitment) to read, read, read the research, take some highly recommended courses about infant feeding, find a mentor whom you can observe and learn along with. The things in life that we become successful at are rarely if ever easily attained. Allow yourself the time and support required.

Problem-Solving with Catherine: 3-month-old with TEF and Vocal Cord Paralysis


QUESTION: I am currently working with a 3 month She had a TEF repair and has a paralyzed left vocal cord. Her most recent MBSS on 9/15/22 indicated delayed initiation, reduced tongue base retraction, reduced laryngeal sensation and primary concern being uncoordinated SSB. She has a PEG tube, and they recommended slightly thickened breast milk via Dr. Brown’s Level 1 and PO intake to be limited to 2 practice feeds daily up to 60 mls. Practice feeds have been going really well, per data her Mom is taking at home, she is slowly increasing volume, reducing the time it takes to consume practice feeds and feeds have been pleasurable with interventions (elevated side lying on right side, external pacing ever 4-5 sucks and thickening breastmilk). Mom also indicates she seems very fussy when the bottle is removed, as she would like to keep eating. Should I ask the medical team about offering oral feeds for a certain length of time (15 minutes) at each tube feeding time if she is showing readiness and as long as she maintains homeostasis and whatever she doesn’t take orally, provide through the tube. She did aspirate thin breast milk her last two swallow studies.

CATHERINE’S ANSWER: Sounds very risky for airway invasion given impaired swallowing physiology in the setting of her co-morbidities. Do we know that in the VFSS thickened EBM was objectified as to its effects? EBM is super thin so when we thicken it slightly and use a Level 1 Dr Brown’s, it seems like that might be too fast flow to minimize air swallowing and bolus misdirection, in the setting of a L VCP and her pathophysiology. What thickener was objectified during the study? Did the radiologist look at upper esophageal function with thickened EBM during the study? How did the swallowing physiology look with the thickening – safe? precarious but no witnessed airway invasion? penetration without aspiration? Thickening may create increased challenges for resistance to bolus flow through the anastomotic site. When as the last UGI/esophagram to objectify whether there is a narrowing? When as she last dilated? Our surgeons typically dilate about every two weeks through the first two years of life. based on what I understand at this point, I would recommend not PO feed until these pieces are sorted out but continue to offer pacifier dips for purposeful swallows to keep her oral-sensory-motor system primed for return to PO.

Lifelong Learners Join Catherine in Houston

My final seminars for 2022 held at Texas Childrens Hospital in Houston brought together SLPs and OTs from across the US and Canada, including Stephanie, pictured with me above. From new graduates to seasoned therapists, we shared complex patients, and problem-solved the “bigger picture” as our framework for interventions. Such a great opportunity to learn along with each other, and to have the time to grow our critical thinking skills that underpin swallowing and feeding practice, from infants through adolescents. Our conversations and discussions helped each of us realize that the challenges we each face are not unique, and we are all in this together. I can’t wait to continue the conversation in 2023!

State-of-the-Art NICU Practice: Catherine Shaker and Suzanne Thoyre

Just returned from Houston after presenting with my colleague, Dr. Suzanne Thoyre, a gifted and remarkable researcher and neonatal nurse. The attendees came from across the US to share our common passion for infant-guided co-regulated feeding in the NICU and after discharge.

Our Early Feeding Skills Assessment Tool was the framework for advancing cue-based feeding, problem-solving challenges in the NICU and beyond, getting everyone “on the same page” through a common language, and supporting parents in building a relationship with their infant through feeding. We all left renewed and empowered to be the change … and with a solid path forward.

Catherine Shaker Seminars: “Formula One” Style in Austin!

     The flagman waves the chequered flag as Red Bull's Dutch driver Max Verstappen crosses the finish of the Austrian Formula One Grand Prix in...

Formula One, part of the US Grand Prix, came to Austin in October and so did I!

The Feeding and Swallowing Team at Dell Children’s were amazing hosts! Speech-Language Pathologists and Occupational Therapists joined us from across the US and Canada to learn interactively along with each other, focusing on a wide variety of practice settings. In the Cue Based seminar, Dr Thoyre and I guided the group in higher level conversations about complex feeding challenges in the NICU and after discharge, watching and scoring videos of neonates feeding and problem-solving next steps. In the Pediatric Swallow Studies seminar, we discussed unique components of the swallow pathway across the pediatric age span, and then peeling apart the pathophysiology and its implications.  In the Advanced Dysphagia seminar, we looked at critical thinking for decision-making, problem-solving and interventions for our neonatal through school aged patients.  It was also a great opportunity to share ways of navigating the practice challenges that each of us faces on a daily basis. It reminded us that we are not alone. One attendee commented: “I feel rejuvenated and validated in my practice, and our conversations reinforced my values as a clinician. ” We all walked away feeling renewed.

Problem-Solving with Catherine: 5-year-old with Athetoid Cerebral Palsy

QUESTION: I work in an outpatient pediatric rehab setting and recently saw a 5-year-old boy with athetoid cerebral palsy (CP) and frequent tonic reflex. His suck-swallow-breathing coordination is poor (multiple suckles followed by multiple swallows, then gasp for air), wheezes heavily, and often he has difficulty clearing his phlegm, has poor lingual range/control, uses phasic bite when foods presented. Parents have not had a VFSS done before.
 His parents “force” feed him with bread, which often stays in his tongue/sides of roof of his mouth. With thin liquids fed with a bottle, anterior spillage occurred (he can’t seal with his lips). Except for liquids (bottle-fed) he is often in distress during mealtimes. My other colleagues reported that he was also fed with rice. I tried educating parents and demonstrated to them how he handles puree and thickened milk much better, but they were against the recommendation, and stated that what I interpreted as distress (e.g., tensing/tightening his lips, head turn, increased tonic reflex, protesting (tensed vocalization) during mealtimes, and crying), is just him trying to eat. They claimed that whenever he attempts to do anything, that’s him tensing up, so they continued to ignore my advice and called my observation a ‘cookie cutter’ statement from textbook, which doesn’t apply to their boy. They said the child has never choked with bread all these years, why stopped him now?
I’ve observed him smiling and relaxed when he’s in comfort, and in my experience, if a diet is too difficult for a non-verbal child to manage, these are signs of distress.  He is quite intentional with his communication (smiles and looks at you if he wants an action/object), it’s hard for me to understand where his parents’ perspective.
I wanted to run by you to see if I might have misinterpreted this child’s body cues. What other strategies can you use to convince parents?
I referred them for a VFSS, so they can at least ‘view’ what’s happening when their child’s eating.

Our children with athetoid cerebral palsy typically present with complex swallowing/feeding challenges similar to those you describe and are very often fragile feeders. Their lack of postural stability and excessive postural mobility provide a poor base of support for the head/neck and oral motor/laryngeal/pharyngeal control along the entire swallow pathway. What you are seeing is indeed worrisome related to the swallow-breathe interface, likely caused by “problems down the line” as part of an overall unstable hyolaryngeal and esophageal complex. This affects not only chewing but the foundations for even swallowing saliva with integrity, and, as such, can often create the perfect storm for airway invasion, both silent and symptomatic. Safety of his liquid swallows is very likely adversely affected as well, especially given that the tongue plays a key role in liquid control and transport. The anterior spillage you describe has many aberrant components beyond lip control that likely do impact swallowing integrity and safety, as the entire system must work together in synergy. He likely lacks the stability and control for any solids, both purees (that may lead to stasis after the swallow) and the “pieces” that likely disperse and can be “underperceived” by a sensory system that is also likely adversely affected, given the overall neuromotor picture. The overt distress behaviors you have witnessed are a typical constellation with this diagnosis and its functional implications. His behaviors to some extent reflect what we call adaptive behavior, i.e., refusals and struggle that likely reflect his fear, learned discomfort and indeed possible airway invasion, that then lead to maladaptive feeding/swallowing behaviors. For families, this long-observed feeding behavior has perhaps become what they see as “just him” when he eats or drinks… much like an NICU nurse who at times may view the excessive WOB and tachypnea we witness at feedings with an infant with CLD as “just who the baby is”. But we know that, who that baby or child “is” is indeed worrisome. It reflects risk and is not then “ok”, when it comes to airway protection and indeed neuroprotection, for both children with complex co-morbidities, and for infants.

I suspect this little guy has learned to “struggle through” his parents’ well–intentioned feeding approach, sadly. They don’t understand his feeding behavior and its actual significance, which is his communication to them. And they are likely still grieving the loss of the normal child their hearts expected, so your thoughtful and likely quite accurate assessment of risk is something they may not want to hear, which is understandable in many ways. Our hearts go out to them.

Trust your instincts. The VFSS will be important to help them see the “why” behind his struggles. They are fortunate to have you in his corner.