Problem-Solving with Catherine: Is Alimentum formula considered a thicker formula?

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QUESTION:

Is Alimentum formula considered a thicker formula? We have a baby that is adjusted to 37 weeks and two days and was put on the one time use Similac standard flow nipple (clear ring) that per Pados’ research is “very fast”. Our med team had nursing get nipple from our term baby floor and are using it because the Similac slow flow (yellow collar) nipple was getting plugged. However, there was a feeding when baby coughed and dropped saturation rates to the mid-80s with this faster flow nipple. I was not aware Alimentum was thicker so wanted to hear what your experiences are. I’d rather use a quality commercial nipple so at least it’s the same exact flow rate every time for starters.

CATHERINE’S ANSWER:

Alimentum is a hypoallergenic formula that is typically thinner and not typically perceived as “thicker” or likely to cause a clogged nipple. The reason for the reported observed lack of flow through the Sim Slow flow may have been the nipple ring being overly tightened, which creates a vacuum. We don’t know anything about the infant’s GA, which research tells us is more predictive of feeding problems than PMA. This infant’s history and co-morbidities may indeed profile greater risk for airway invasion with the medium flow clear ring nipple. The coughing and deep desaturations are indeed worrisome , and both are correlated with silent aspiration in the research by Ferguson. Agree a slower flowing nipple is indicated based on what we know, and perhaps other protective interventions ( swaddled sidelying, co-regulated). The Dr. Brown’s preemie flow may provide protection and avert over tightened ring. Have you had the opportunity to do a clinical assessment, and can you tell us more about history and co-morbidities? Understanding the bigger picture always helps me understand the “why” and consider both next steps and interventions more thoughtfully.

Alimentum is so super thin at baseline, that even when it is fortified 24 cal it still is quite thin and watery, in my experience. I do hear some caregivers comment that it is “thicker” when 24 cal but I suspect that is conjecture – based on the idea that typically adding something might increase viscosity. But it’s all about the baseline integrity of the fluid. Alimentum at baseline is 80% water by composition and extensively hydrolyzed, so very watery. Often, those infants who require 24-cal Alimentum have multiple possible reasons why drive to feed and volume transferred may be suboptimal. The assumed culprit is often “its thick” but, as you know, our fragile feeders often have complex underlying issues that can adversely affect feeding success.

 

Problem-Solving with Catherine: Repeat Swallow Studies Post-NICU Discharge

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QUESTION: What is the typical time for follow-up VFSS for discharged NICU baby who is on thickened feedings? Our team has been recommending 6 to 8 weeks following VFSS. We are finding that there is some improvement at 6 weeks but not enough to change formula thickness.

CATHERINE’S ANSWER:

Because I find every infant is unique, we don’t utilize an arbitrary time frame, but instead determine that with the gestalt of each patient, and then discuss with the team.

Considerations I use include: infant’s history and co-occurring comorbidities, etiology(ies), nature of pathophysiology, how precarious swallowing appears even with thickening, complexity of interventions required to establish safe swallow, anticipated compliance with interventions post-discharge.

For example, a former 24 weeker with slowly resolving CLD, discharged on oxygen with laryngomalacia with the same swallowing pathophysiology as an infant born at 37 weeks IDM would most likely have a repeat VFSS earlier and have post-discharge surveillance more frequently. Ideally, we want to allow enough time for resolution of the etiology or the factors that underpin the swallowing pathophysiology, but not too much time —so that too must be tempered with risk-benefit of prolonged thickening, radiation exposure and how safety may change overtime, both for the better or the worse, depending on the infant and the bigger picture. It’s the art and science of what we do.

In re-assessing potential changes in swallowing physiology in the repeat VFSS, we may not be able to wean thickening based on new data. The data we gather will hopefully better guide interventions that would be occurring aside from thickening, and allow us to objectify potential new interventions and their impact. Re-objectifying physiology in a VFSS allows us to gather objective data on the impact of weaning thickener on physiology itself,  avoiding a narrow focus on only aspiration. It should help optimize the risk-benefit ratio inherent in our clinical decision-making, especially for our most fragile feeders.

Rather than having an arbitrary time frame, consider recommendations that are patient specific based on the domains above. As I always like to say, “in the NICU, co-morbidities matter”.  That applies to this question as well. So perhaps collect data for the team that may yield “co-morbidity-based” time frames that could be your soft “guidelines” — with the understanding that the final recommendation will be infant-specific.  Again, it’s the art and science of what we do and part of the value we bring to the NICU team.

If I were to average the data over many years of practice, I suspect the repeat studies post-discharge from the NICU tend to be between 6-8 weeks post discharge. I hope this provides some food for thought.

Happy Thanksgiving 2024 from Catherine Shaker

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                                                                                  This Thanksgiving, I want to share my gratitude for the opportunity to connect 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

  

May your holiday season be filled with joy, love, and moments that matter most.

Problem-Solving with Catherine: Feeding Team “Holding Babies Back” in the NICU ?

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Question:

I’m getting more and more discouraged at the lack of support we get from nursing in our unit. I’ve had 2 families ‘defer’ OT multiple times in the past 2 weeks only to then be told that they feel the feeding team ‘hold babies back’ and we are the barrier to discharge. The wording and behavior is not something you would hear parents say so I can only think where they are getting this message.  These families are getting mixed messages and then there is mistrust which I worry causes further mistrust and lack of follow up on discharge. Any suggestions appreciated.

Catherine’s Answer:

Sadly, this is not uncommon. All we can do really is build relationships with families, with our nursing colleagues and neonatologists, learn along with our nursing colleagues via guided participation, have engaging conversations that reflect our respect for their contribution/perspective, share our key learnings in a collegial way, and always look for opportunities for cross-fertilization of knowledge.

Helping the parent or RN take the perspective of the infant, e.g., “mommy, please give have more time to breathe; I’m not quite ready to suck right now” then explaining how the infant communicated that important message (e.g., by what the caregiver saw, heard or felt), and the change in communication following the caregiver’s infant-guided intervention, always seem to change the conversation. It really is about the infant and so taking it back to that foundation helps others really understand that “every feeding experience matters”, as I like to say.

I have found over the years, in a large Level IV (160 beds) and as I teach across the country, that, like any other situation in life, we often cannot change others, but we can change how we respond and what we expect of ourselves along the way. I always say that life in the NICU is a journey not a destination. It requires us to pick ourselves up and dust ourselves off every day. Hang in there and focus on the good that you do, my friend.

Catherine Shaker Seminars: Wrapping Up 2024 Texas Style!

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During 2024, I traveled from the heartland to Texas and to the East and West  coasts, and met (and re-connected with !)  some amazing people along the way. From past attendees who once again joined me in Sacramento, to the dedicated team at Wake Med Medical Center, to the amazing NICU nurses who learned along with STs/ OTs/PTs at my NICU seminar in Texas, to the staff and children at Morristown Medical Center, and the dynamic team at Community Health in Indy. From all coasts and around the world (Canada, Dubai, Spain, Japan, the UK) therapists joined us 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 navigating the practice challenges each of us faces on a daily basis. We each left feeling renewed.

I am finalizing next year’s schedule, which will take me across the US….. to Columbus OH, Dallas, Houston and California.

Sign up for my blog on my website to receive a notification when my 2025 Seminar schedule is posted.

I continue to be grateful for each of you who shares my passion for neonatal/pediatric swallowing and feeding, and lifelong learning. I hope our paths cross in 2025!

Catherine

 

Some of my favorite comments over the years:

“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

 

Problem-Solving with Catherine: Clinical Weaning 3 y/o with Down Syndrome

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Question: Looking for input on weaning thickener for 3 y/o with down syndrome. Attempted the systematic weaning protocol, but patient did not tolerate past 20% decrease. Patient previously used Vital Stim with minimal results, but I’m unclear on how long it was utilized. Any courses or articles people can point me to help? Thanks in advance. I feel like I keep taking courses and reading things, but there’s just so much to know and keep up with. It’s kind of overwhelming.

Catherine’s Answer: The clinical weaning program for our patients with Down Syndrome will require the use of objective data via VFSS regarding the impact of the change on physiology and airway protection. The literature, much of it recent, is worrisome for silent aspiration due to pathophysiology, likely related to altered sensory and motor components for swallowing. Weaning without the benefit of objective data about the impact could inadvertently adversely affect airway protection for some children. Boston Children’s did a study showing that our clinical impressions about airway invasion risk are often not reliable. That means we must carefully weigh the risk-benefit ratio of clinical weaning for each patient. No intervention is for all patients. It is only as good as the skill of the clinician to problem solve its appropriateness given the big picture.

Follow-up question from therapist: What would you recommend for patients that would like to work on weaning as a VFSS is not typically available in most settings? I’m trying to be explore as many options as possible to provide support to parents. It’s possible they may not be able to be weaned, but I want to make sure I’ve got explored all options to support this family.

Catherine’s follow-up answer: Can you tell me more about history and co-morbidities, and the impressions about swallowing pathophysiology from the most recent VFSS, what level of thickening is he on, by what utensil, is that what was originally objectified on the most recent VFSS (or is there no objective data for that thickening with that utensil?) , respiratory history and interval hospitalizations, what you are seeing clinically? I know that’s a lot of questions but without that info it’s like pulling something out of the air – not useful. Each piece of data has meaning to me as I problem-solve and do a mini-differential (with the caveat that I don’t really know the child and have not laid eyes/hands on the child). The risk is much higher without objective data from a VFSS…knowing more about the bigger picture will help me consider the potential risks to pulmonary health for this child. Even if the VFSS isn’t available in the setting in which you work, such as EI, working through logistics to obtain objective data about the impact on swallowing physiology through a VFSS will always support a more protective plan, especially in the setting of DS. If I were not practicing in acute care, but were in EI, with what I know about the patient so far, and have read in the literature, I’d be wanting objective data from a VFSS. Recent papers have stated that “the treatment should be based on data acquired from an instrumental assessment…”. That causes us to take pause, given that if there are unintended consequences to your plan of care, an expert witness may cite these papers. Careful assessment of the risk-benefit ratio of proceeding without objective data is the treating clinician’s judgement. As a former expert witness, I always to try in my clinical practice to minimize my risks as a professional, knowing that litigation can sometimes come from unintended sources and families in grief. Please don’t take these comments as criticizing your practice — they are not meant to at all, but rather to add another voice of experience that might help someone out there. Your post clearly supports your critical thinking, and your little patient is fortunate to have you supporting the family and safety.

Addendum: Selected References

Velayutham, Priatharisiny, Alexandria L. Irace, Kosuke Kawai, Pamela Dodrill, Jennifer Perez, Monica Londahl, Lauren Mundy, Natasha D. Dombrowski, and Reza Rahbar. “Silent aspiration: who is at risk?” The Laryngoscope 128, no. 8 (2018): 1952-1957.

Weir, K., McMahon, S., Barry, L., Ware, R., Masters, I. B., & Chang, A. B. (2007). Oropharyngeal aspiration and pneumonia in children. Pediatric pulmonology, 42(11), 1024-1031.

Hendrix, J. A., Amon, A., Abbeduto, L., Agiovlasitis, S., Alsaied, T., Anderson, H. A., … & Yi, J. S. (2021). Opportunities, barriers, and recommendations in Down syndrome research. Translational science of rare diseases, 5(3-4), 99-129

Tutor, J. D. (2020). Dysphagia and chronic pulmonary aspiration in children. Pediatrics in Review, 41(5), 236-244.

Bush, D., Galambos, C., & Dunbar Ivy, D. (2021). Pulmonary hypertension in children with Down syndrome. Pediatric pulmonology, 56(3), 621-629.

Brumbaugh, D. E., & Accurso, F. J. (2002). Persistent silent aspiration in a child with Trisomy 21. Current opinion in pediatrics, 14(2), 231-233.

Stanley, M. A., Shepherd, N., Duvall, N., Jenkinson, S. B., Jalou, H. E., Givan, D. C., … & Roper, R. J. (2019). Clinical identification of feeding and swallowing disorders in 0–6 month old infants with Down syndrome. American Journal of Medical Genetics Part A, 179(2), 177-182.

Nordstrøm, M., Retterstøl, K., Hope, S., & Kolset, S. O. (2020). Nutritional challenges in children and adolescents with Down syndrome. The Lancet Child & Adolescent Health, 4(6), 455-464.

Problem-Solving with Catherine: NICU VFSS and Indwelling NGT

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Question: I have been searching through your publications and have not been able to find this answer and I am curious if you could help me. I have been getting questions regarding our swallow study process and the validity of a swallow study when a baby has an NGT. Our physicians are questioning if we need to complete a swallow study with and without an NGT. Is this necessary? Thank you for your support and all the great work you do!”
Catherine’s Answer:
I think the key considerations would include:
  • Having the feeding “environment” for the VFSS the same as the typical feeding environment or you add an artifact to the data set. So if there is an indwelling NGT, that is the typical feeding environment for that infant. If the NGT is to be removed in a few days and “no NGT in situ” will be the typical feeding environment, then that would be a reason to objectify physiology without the NGT in situ. But that would be an unlikely plan if we are going to radiology.
  • Observing under both conditions increases radiation exposure which we know the AAP advises against unless we expect new data
  • Recognizing that most preterms are PO feeding with an NGT in situ for a period and they still progress to full PO. It in and of itself does not appear to be a variable adversely affecting progression. It’s not typically the indwelling NG tube that is the problem, it’s the impact of the infant’s unique comorbidities (based on research about co-morbidities) affecting the swallow-breathe interface.
  • We have no data that I am aware of in an RCT regarding this question specific to the NICU. The only citations I know of are below. Edwards et al (7 DOL to 13 years) does not even look at the etiology for the aspiration events so we cannot conclude that the NGT being in situ was “causal” — only that it was a “co-occurring” variable in this cohort. I think the conclusions are not warranted. The distinction between what is “causal” and what is “co-occurring” is rooted deeply in medicine — and should be with our differentials as well.
  • My clinical wisdom over almost 40 years in Level III and level IV NICUs suggests as a guideline we leave the NGT in during the VFSS. The pathophysiology witnessed has never appeared to me to be related to the effect of the NGT but rather to other factors, often related to infant’s unique history and comorbidities.

Relevant references~

  • Alnassar, M., Oudjhane, K., & Davila, J. (2011). Nasogastric tubes and videofluoroscopic swallowing studies in children. Pediatric radiology, 41, 317-321. Quoted Summary: The presence of a nasogastric tube does not alter the findings of VFSS; however, it might increase the incidence of respiratory compromise when aspiration is present.
  • Edwards, S. T., Ernst, L., Sherman, A. K., & Davis, A. M. (2020). Increased episodes of aspiration on videofluoroscopic swallow study in children with nasogastric tube placement. Plos one, 1   Quoted Results: Sixty-three children with NG tubes were identified, along with 63 age and sex matched children without NG tubes in place, at the time of VFSS. Ages ranged from 7 days to 13 years. The NG group had a significantly higher proportion demonstrating aspiration (46% vs. 23.8%, p = 0.0089). Quoted Conclusions: This study supports the need for further prospective evaluation of NG tubes and their effect on swallow, as well as more careful consideration of prolonged NG tube placement in patients with feeding problems. Consideration should be given to removal of the NG prior to VFSS to prevent the impact of NG placement on results of the swallow study which could lead to inappropriate modifications to the patient’s care plan.

Catherine’s Research Corner: Oral feeding dysfunction in post-operative infants with CHD

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In our neonatal/pediatric population, often the need for TEE (Trans Esophageal ECHO),  a the surgical procedure that  involved the aortic arch, and/or both intra-operative and post-operative events —in the setting of the inherent neurodevelopmental risks for the CHD population — all raise our index of suspicion when we are re-consulted post-op.

I have been meaning to post this article by the team at CHOP for my peds colleagues who follow our infants/children with CHD. It suggests the most common risk factors associated with poor feeding for infants with Congenital Heart Disease at time of discharge were: birth weight (36% of included studies), gestational age (44%), duration of post-operative intubation (48%), cardiac diagnosis (40%), and presence of genetic syndrome or chromosomal anomaly (36%).

Jacobwitz M, Dean Durning J,Moriarty H, James R, Irving SY, Licht DJ, and Yost J (2023) Oral feeding dysfunction in post-operative infants with CHDs: a scoping review.Cardiology in the Young 33: 570–578.doi: 10.1017/S1047951122001299 (available on Google Scholar)

While pre-operatively the presence of complex co-morbidities portends for more worrisome post-op feeding challenges, in this population the well-intentioned “push” to PO feed or the “push” to return to PO feeding post-op in a regimented way, often sets the stage for volume-driven stressful feeding experiences (for infants and children alike). That can then often provoke the onset of feeding refusals and indeed aversions, and further exacerbate baseline risk for enduring feeding problems. Our partnership with the PCVICU team, including families, is so important to optimize feeding outcomes in this at risk population and support joy in feeding for a lifetime.

I hope this informs your practice as it did mine.

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

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Chart Label - Thickened Liquids

QUESTION:

Thoughts about completing a wean for infants as young as 8 months? (this patient I’m considering a thickener wean with is 12 months gestational age, 8 months correct, ex 22-weeker)

How do you manage nipple flow rates as you progress through the weaning process? i.e., patient is on a level 4 nipple, consuming formula thickened with 1 tsp per fluid oz.

What if the patient takes varying amounts of formula per feed? i.e., patient will sometimes consume 4 oz then the next feed, will consume 5 oz. I work primarily with low-income families in which parents use WIC, so I’m trying to prevent them from wasting formula. The study I’m referring to (Wolter et al 2018) uses 6 oz in their recipe.

I’m fairly new to utilizing this process in my practice.

CATHERINE’S ANSWER:

This infant sounds quite complex. I am wondering about the swallowing pathophysiology objectified in radiology that led to the need for thickening and how precarious that physiology was, even with thickening. The majority of our former 22 weekers have enduring multiple complex comorbidities and 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 the course of a true feeding. The objective data from a VFSS about the can be often surprising and indeed is often necessary for our very fragile extremely preterm infants with complex histories…. versus weaning based on subjective/clinical impressions only. The risk-benefit ratio of clinical weaning for each patient must be carefully determined, especially with former 22 weekers.

The team at Boston Children’s has provided us with a wealth of research to help inform our practice. This paper referenced below details the intervention—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 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 im0plication  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.

Catherine’s Research Corner: Facilitating Pediatric Patients During Videofluoroscopic Swallowing Studies

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The VFSS (videofluoroscopic swallowing study) requires a high level of clinical reasoning and critical thinking. Pediatric therapists  utilizing best practice during videofluoroscopic swallow studies recognize that reading the  x-ray images in-and-of-itself is insufficient for completing a differential, generating an impression and prescribing a plan of intervention. Multiple considerations are essential, including interpreting the radiographic data in the setting of that child’s unique history, comorbidities and and clinical presentation. Building on their previous publication Smith & Barkmeier-Kraemer, 2022, there are logistical considerations that the authors delineate to optimize clinical yield and plan of care.

Citation:

Smith, L. S., Brinker, K., Jones, C. E., Ray, M. H., Taylor, H. M., Gardiner, R. T., & Sauer, T. M. (2024). Facilitating Pediatric Patients During Videofluoroscopic Swallowing Studies. Perspectives of the ASHA Special Interest Groups, 9(4), 1119-1133.

 

Quoted from the Abstract:

Results/Conclusion:

Facilitative techniques during pediatric VFSS benefit the obtaining of accurate diagnostic results to guide pediatric feeding disorder management and recommendations.

The pediatric videofluoroscopic swallowing study (VFSS) is an imaging procedure that captures moving X-rays while infants or children swallow liquids or solids containing barium. The process allows evaluation of oral, pharyngeal, and upper esophageal function. The purpose of the study is to define swallowing function with the intent of designing appropriate care plans for patients with disordered swallowing, also known as dysphagia. The management of swallowing problems can be complex, as dysphagia exists within the larger context of pediatric feeding disorder (PFD; Goday et al., 2019). An accurate instrumental assessment of dysphagia through VFSS is a critical diagnostic study for many pediatric patients with PFD, and therefore crucial to the formulation of individualized and appropriate treatment plans.

Conducting a pediatric VFSS in a manner that accurately reveals swallowing pathophysiology can be challenging due to a variety of factors present in testing situations with infants and children. Arvedson and Lefton-Greif (1998) provide detailed information regarding the conducting of VFSS in their manual: Pediatric Videofluoroscopic Swallow Studies: A Professional Manual With Caregiver Guidelines. The American Speech-Language-Hearing Association (ASHA) Practice Portal provides guidance on conducting comprehensive assessment of feeding and swallowing disorders, including instrumental evaluations. Speech-language pathologists (SLPs) are instructed to conduct assessments in a “sensitive and responsive manner” (ASHA, n.d.), which implies support of the caregiver and patient throughout the evaluation process.

SLPs may facilitate inpatient and outpatient children ages birth through 18 years in multiple ways to increase the likelihood of obtaining an accurate and representative sample of swallowing during VFSS. Clinical efforts have revealed effective techniques for use during pediatric VFSS, to achieve studies of higher diagnostic value. These techniques are offered herein as applicable with various pediatric patients, dependent on SLP judgment. The Pediatric Videofluoroscopic Value Scale (pVFSS), a novel tool used to summarize a clinician’s level of trust in VFSS results, includes five categories (Smith & Barkmeier-Kraemer, 2022). Facilitative techniques for each of the five categories, namely, feeding engagement, crying, volume consumed, bolus size, and method, are discussed in this clinical focus article.

Shaker Seminars in Raleigh: Sharing a Common Passion and the Latest Evidence

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I just returned from a  wonderful week of teaching in Raleigh at Wake Med.

Here I am with Juliet, Lesli and Lindsay, who are part of the Wake Med SLP team~

Pediatric and neonatal therapists from across the US joined me to network, take deep dives into the evidence, reconsider and reframe fundamentals, share clinical experiences and key learnings, and problem-solve both hot topics and complex patients. We all left feeling renewed and knowing that we are all in this together.

It is such a gift to have the opportunity of in-person engagement that generates new friendships and colleagues that will last a lifetime. I am so looking forward to heading to NJ in September.

Dysphagia Cafe: Pediatric Feeding Partnerships with Caregivers

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Caregiver feeding a baby

Congratulations to our SLP colleague, Tovah, for her thoughtful article just published on Dysphagia Cafe.

The insights she offered should be required reading for all graduate students hoping to support infants, children and families with feeding and swallowing challenges. The human connections we choose to form and nurture with families are perhaps the most important and rewarding part of what we are blessed to do as neonatal/pediatric therapist. Tovah captured the heart of the passionate, yet gentle spirit required, and then laid out a path to begin that journey, or indeed to make one’s journey even more impactful. I hope you enjoy it as much as I did.

Catherine

Click here to access

~Shared with permission~

 

Catherine Shaker 2024 Seminars: Look Through a New Lens

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“The real voyage of discovery consists not only in seeking new landscapes but also in looking through a new lens.”
Join Catherine in 2024 for advanced clinical learning opportunities in Indy, Raleigh, Morristown NJ, and the Dallas area ….
  • 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

An interactive welcoming learning environment……with multiple planned times for dialogue and questions, problem-solving your patients, sharing our collective wisdom, discussing the evidence-based research…and our shared clinical challenges.

Our discussions will include critical thinking for all our patients, no matter the age. It’s not just learning “what to do” clinically but thoughtfully considering what not to do and why.      Because every feeding experience matters………

Click here for Catherine Shaker Seminars 2024 Brochure
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Problem-Solving with Catherine: Intubated Infants and Milk Drops

Catherine Shaker Seminars Leave a comment

 

Premature baby 'size of a palm' home after 400 days in KKH, parents learn to rise above heartache - TODAY

Question: Our health care system is looking at the pros/cons of administering maternal breast milk swabs vs drops via syringe to early preemies and other infants who are intubated. I am aware that the use of syringe is recommended for initial colostrum, but I question if this is a safe practice beyond that phase. Our feeding educators and micro-preemie champions feel that best practice is to administer swabs vs syringe, which is difficult to control. I would appreciate your thoughts and references on this matter.

 

Catherine’s Answer: The benefits of EBM from the first moments of extrauterine life have been well-documented. That said, some of the applications of this concept are somewhat worrisome and need to be grounded by our understanding of swallowing physiology, its emergence in the setting of prematurity, the impact of an ETT and the co-morbidities that co-occur for preterms and sick newborns who require neonatal intensive care. I have seen commentary from a therapist on social media saying, ” We start as young as 24 weeks. 0.2 mL”    While we know the fetus at 24 weeks of life is swallowing amniotic fluid for motor learning in the intrauterine environment, the extrauterine environment cannot provide the same underpinnings when a caregiver delivers fluid, even with the best of developmentally supportive infant-guided care. 

The complex and precarious nature of the swallow-breathe interface in these fragile infants is not always fully understood, so the need to pause and fully consider the risk-benefit ratio for such an intervention at that particular time in the infant’s recovery may not be fully appreciated. If there is an ETT in situ, then it may act, as our ENTs say, as a potential conduit for the milk drops (and EER/LPR for example) to invade the airway, silently or symptomatically. I would suspect that syringe delivery of a bolus would pose a greater risk, but no one to my knowledge has studied that question.

That does not mean pacifier dips or milk drops aren’t a valuable intervention, but timing and readiness are key considerations for any intervention available to us. I use it often in the NICU to promote both neuroprotection, motor learning for swallowing (often truncated by limited intrauterine learning secondary to preterm birth) and underpinnings for future PO attempts (so incorporate organized root-to-latch sequence, resting, and co-regulated pacing). Even for sick newborns with co-morbidities that predispose then to feeding/swallowing problems, this has clinically appeared to be quite helpful for the infant and as a learning process (via guided participation) for families in preparation for offering an infant-guided approach to PO feeding. 

I hope this was helpful. As we both know, there are rarely black and white answers to our clinical questions. They require thoughtful deliberation and critical thinking to minimize risk for these most fragile of our patients.

 

 

Shaker Pediatric VFSS Seminar: Evidence-base, Physiology and Critical Thinking

Catherine Shaker Seminars Leave a comment

QUESTION: I am considering the Pediatric Videofluoroscopic Swallowing Studies course. I am not in the hospital setting but I go with my patients almost always to their studies. I’m thinking this is going to be super beneficial for me with advocating for patients. Often times no compensatory strategies are used, I’m told they can’t use cold or carbonated liquids, etc. When in previous settings I have known these things not to be the case. Thoughts? Am I thinking correctly that this would be helpful for a private practice SLP as well?

CATHERINE’S ANSWER: It is wonderful that you can attend the VFSS to be part of the problem-solving. Yes, the course will absolutely be valuable to you. I designed it to fill that void that is out there, as well as to support well-thought-out studies that look far beyond “aspiration” and “thickening” It is not the radiographic image alone that contributes to an impression and plan of care. The course is designed to provide the latest evidence-base regarding evolution of/progressive changes (with age) in both structural relationships and physiology from birth through the age of about 6 (based on the data and research we have), when the swallow becomes adult-like in all respects for the typically developing child. This information helps to understand where to specifically map interventions. The focus of the course is not on looking for or finding “aspiration” but on objectifying swallowing physiology (or pathophysiology), considering how that physiology may impact airway protection and relative risk for airway invasion,  and then critically considering, in the setting of that child’s unique history and co-morbidities, how to optimize safety —and objectifying potential interventions there in radiology, finally providing the thoughtful impressions that round out the picture of mealtime impact for the team. These underpinnings for critical thinking are key for any treating therapist, even if that therapist does not conduct swallow studies. Making sense of the dataset, if useful data is gathered, is not the sole domain, nor the sole responsibility of the therapist doing the study. Understanding physiology and its connection to function and intervention is essential for treating therapists too—That knowledge base makes us more effective problem-solvers and critical thinkers every step of the way. So much underpins what we do as swallowing/feeding specialists. Physiology, and the impact of pathophysiology, is at its heart.

Some feedback from previous attendees to my Pediatric Videofluoroscopic Swallow Studies seminar:

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

Catherine’s Swallow Studies course was the most detailed education I have had related to the dynamic interaction of the oral, pharyngeal and esophageal phases and how they play on one another. Her breadth of well-rounded knowledge and ability to easily relate it to practice is wonderful. She is so approachable which makes it a comfortable environment. Lisa, OTR

The information presented by Catherine in the VFSS course was so well researched. I feel confident that I can add all of this info to my clinical knowledge, and I know where to find more info (via the many citations)! Kari, SLP

As an outside provider (not in a hospital doing VFSS), this was great info on how I can communicate what I’m looking for and why I’m recommending a VFSS. The time watching videos of swallow studies helped my brain process the reports I read when I can’t be at the actual study in person. Minnie, SLP 

Catherine had a great way of effectively presenting information through multiple modalities. The x-ray stills, videos of so many different etiologies and the case studies in radiology have tremendously increased my confidence with pediatric MBSS. Heather, SLP

This course gave a great perspective on how to effectively determine and describe a disruption in swallow physiology for parents, physicians and other professionals. I loved the video examples! Rachel, SLP

The swallow studies course is an excellent synthesis of the dynamic aspects of pediatric swallowing and an exquisite way to transition to VFSS. Monique, SLP

What a great course on pediatric swallow studies. Now I know to think physiology, not just aspiration and penetration!! Yeah! Samantha, SLP

I am surprised and enlightened by how much I have learned considering I have been doing pediatric VFSS’s for 15 years! Natasha, SLP

I am just starting my VFSS training, and this course will help tremendously! A wonderful opportunity to consider differentials for many different clinical presentations. Jennifer, SLP