The Early Feeding Skills Assessment Tool (EFS) now available

I am pleased to announce that through my collaboration with Suzanne Thoyre, RN, PhD The Early Feeding Skills Assessment Tool (EFS) is now available for download and use with you babies in the NICU and through adjusted age 6 months.

The EFS is a tool to help us:

The EFS has evolved over the years as a wonderful guide to cue-based feeding in the NICU. I especially am proud of it because it looks at feeding from the infant’s perspective and is grounded in physiology. It reflects how I conceptualize feeding in the NICU, which I refer to as “infant-guided”, i.e., a dynamic approach based on contingent co-regulation between infant and caregiver. That maybe a parent/family member, a nurse, or a therapist.

The tool is also based on dynamic systems theory (that multiple systems synergistically affect each other during feeding) and these systems are assessed dynamically throughout an entire feeding, to arrive at a gestalt. Capturing variability across the entire feeding is a critical part of the analysis/integration of information. The items are designed to capture the variability in the infant’s learning of the foundational components of feeding skills, the continuum of that learning, and the emergence of skills; so it assesses  whether component skills are not observed, are emerging, or are indeed consistently expressed. It is often used serially to capture developmental progress in feeding over time.

The EFS leads the caregiver, by the nature of how it is designed, to the interventions that naturally flow from the results of the assessment. It profiles interventions to support adaptive function during feeding and swallowing, and therefore interventions for safety.

The EFS is user friendly in that it is not focused on understanding and identifying only isolated oral-motor components but rather making sense of what all caregivers “see” every day when they feed preterm infants–the infant’s communication/cues during feeding. It provides a common language about feeding terminology (such as what do we mean by an infant is “pacing” himself, or what is “coordinated”, for example) to help all team members, including families, get on the same page, so conversations and report have common meaning. Psychometrics have been completed and published soon.

Join us in Atlanta on August 15-16, 2018 for a live learning event on utilizing the EFS in support of Cue-Based Feeding in the NICU. Stay tuned for details on my website soon!

Use this link to register and download the EFS

Shaker ASHA Blog: Preparing for the NICU

Do you hope to get a coveted pediatric placement during graduate school or for your clinical fellowship experience? Are you interested in an even more specialized subset of pediatrics? Working as a speech-language pathologist in the neonatal intensive care unit (NICU) requires many specific skills. These tiny patients and their families are fragile. The family-centered care we provide as SLPs, in support of neuroprotection, communication and safe feeding, create the foundation for a thriving parent-infant relationship.

Read more here: Preparing For Grad School or CF Placement In The NICU: Part One 

Teaching at Children’s Medical Center of Dallas

My colleague Theresa and I were pleased to welcome therapists from across the United States and Canada to our seminars in Dallas Texas. Children’s Medical Center has several campuses in the Dallas Metroplex and provides services for a wide range of infants and children. Our Children’s House and Specialty Clinics are unique and serve populations in need of specialized expertise in swallowing and feeding. We continue to be amazed by the critical thinking of the therapists we meet at our seminars. Problem-solving case studies and learning from each other provides opportunities for clinical growth and networking. We look forward to returning to Texas in October 2018 for our seminars in Austin!

Problem-Solving with Catherine

Question: I have been treating a 24-month-old little girl that has had a complicated medical past including prematurity (27 weeks gestation with a birth weight of 2.2 lbs. oz..), Down syndrome, AV canal defect, ventricular septal defect, duodenal atresia s/p repair, and respiratory distress in newborn requiring intubation at birth. Additional diagnoses included: bilateral sensorineural hearing loss, GERD, VUR/urinary reflux, anemia, and hypothyroidism.  I started seeing her nearly a year ago and referred her for an OPMS due to frequent upper respiratory illness although she had no outward signs/symptoms of aspiration.  She was found to be aspirating thin liquids and the recommendation was for honey thick liquids and fast flow nipple.  She has done well in therapy and has transitioned to a variety of table with liquids by cup and bottle.  She is returning to pulmonology soon and the doctor wanted to know how she is doing with thin liquids.  I’ve been hesitant to recommend going back to thin liquid without a follow up due to the history of silent aspiration.  Do I try distilled water with nursing to check of O2 saturations to give the doctor feedback? I think I would still want a repeat instrumental since the history of silent aspiration and respiratory illness. Any other thoughts or possible suggestions?  Parents are very nervous with feeding although she has done very well in treatment and the overall frequency of respiratory illness has decreased.

Catherine’s Answer: Sounds like a child with multiple complex co-morbidities that are likely combining to create the etiology for her feeding challenges. From what we understand about her, we don’t know what the etiology of the silent aspiration events was. Without the etiology(ies) and understanding her swallowing pathophysiology, it must be hard to fully understand what to work on to improve her swallow function. That also would inform our problem-solving as to the contributing factors, the nature of the swallowing impairment and potential for improvement, in the context of her medical co-morbidities and multi-system differences. Contributing factors seem to be cardio-respiratory and GI, as well as postural tone, oral-motor and sensory. These likely combine to create risk for uncoupling of swallowing and breathing. The lack of clinical suspicion prior to the original instrumental assessment followed by silent aspiration creates increase risk for her, given her pulmonary status. So, your concerns are appreciated. I think it is uncommon to have infant on honey thick liquids because the risk to aspirate, given such impaired physiology, remains, despite the thickening to honey. And if she does aspirate honey thick liquids, that may create significant challenges for her lungs, given the history we know. That said, she has been on thickened liquids of a year. We typically reassess physiology much sooner in the developing infant with multiple co-morbidities.

Depending on the original data gleaned in radiology, at that time pacifier dips of thin liquid would have been an avenue to allow for purposeful swallows that activate the fast twitch fibers and promote interval sensory-motor learning with tiny amounts of thin liquids. That way when she returned to radiology to relook at physiology, we would be less likely to have an artifact -i.e., lack of careful recent sensory-motor experience with thin liquids that can create a predisposition perhaps to mis-direct the thin liquid. So, dipping the spoon in thin liquids for some tiny tastes may help at this point to safely prepare her while minimizing risk. Of course, there is risk to aspirate the trace tastes used for purposeful swallows, but one must weigh the need to set her up for success with recent sensory-motor experience for a brief period and then take her very soon for a repeat instrumental assessment. With a focus on physiology during the swallow study, and not just whether she aspirates, current data can be provided to guide her treatment. Hopefully interval improvements in the underlying co-morbidities and your good intervention may allow for safe advancement of her liquid diet, even if only in a therapeutic situation, A year is a long time to be on honey thick liquids., and that is not without its own attendant sequelae. You are asking good questions. Keep us posted.


I hope this is helpful.

Outcomes of Congenital Heart Disease

For those of you who provide support to a pediatric cardiovascular intensive care unit, I wanted share this insightful article on outcomes for this unique and special population. It reinforces the breadth of services that as SLPs we can provide and the critical nature of our broad assessment post-op and careful follow-up. I hope it informs your practice as much as it has mine. A fascinating read. Please share it with your cardiologists.

Excerpt: “The risk factors for poor outcome include type of CHD; presence of genetic conditions; fetal and neonatal neuroimaging abnormalities; pre-, peri-, and postoperative factors associated with hypoxia and hemodynamic instability; prematurity; male sex; and family socioeconomic status and resilience. In utero, CHD may affect cerebral blood flow and oxygenation with resultant slower brain growth, delayed brain maturation, and white matter vulnerability. Pre- and peri-operative instability may cause brain injury, such as white matter injury, microhemorrhages, and stroke. Operative factors, such as deep hypothermic cardiac arrest and cardiopulmonary bypass, played a minor role in determining long-term outcomes. Postoperatively, prolonged hospital stay and severity of illness were predictors of worse outcome.”

Outcomes of CHD

I hope this is helpful.


Problem-Solving with Catherine

This question was posted on my colleague Krisi Brackett’s blog and I thought my response might be helpful to my readers as well.

Question: My observation, like other therapists, is that many of the micro preemies and/or babies that have had very involved respiratory issues and complex treatment needs because of these issue, often require increased sensory input related to feeding (temperature variance, thickened consistency).  What we have observed is that these babies often benefit from increased FIO2 during feeds despite having adequate O2 levels.  Do you have any thoughts on this matter?  Our primary Neonatologist says that there is no physiological reason that this rational would be helpful.  I believe the extra flow provides the sensory input that these babies often need, especially while learning to feed.

A few thoughts. “Flow ” and Fi02″ are two different parameters. Due to the concern for the potential adverse effects of oxygen (Fi02), many NICU infants in need of increased respiratory support are weaned to 21% Fi02 with flow. That flow can be delivered via NCPAP, HHFNC, and low flow nasal cannulae. The flow rate itself (PEEP or LPM), has been shown to often help prevent pharyngeal collapse and facilitate maintenance of functional residual capacity (FRC). These two parameters to some extent are likely part of the underpinnings for effective feeding, when WOB and respiratory stability permit PO. However, when an infant is requiring significant Fi02 at baseline, one might question his/her readiness for the aerobic demands of feeding. Depending on the “extra flow” you describe (typically that means for example, PEEP or LPM), it may also create possibly an unsafe feeding environment, as what a conclusion of the recent study by Ferrara et al.   See Ferrara, L., et al. “Effect of nasal continuous positive airway pressure on the pharyngeal swallow in neonates.” Journal of Perinatology 37.4 (2017): 398-403. The answers are not fully in but this well-done paper suggests certain flow may clearly be worrisome for infants requiring intensive care.

Regarding thickening feedings in the NICU –  As I travel and teach across the US about feeding preemies, I am consistently finding that thickened feedings are viewed only as the final consideration after position change, further slowing the flow rate and use of increasing strict co-regulated pacing. The potential adverse effects of thickened feedings are many, and require us as to be “clinical scientists”, i.e., carefully weigh the risk-benefit ratio for each preterm infant, and create a unique algorithm for that infant’s plan of care, in collaboration with the NICU team. Each infant’s history, co–morbidities, respiratory history, and current clinical picture and as well as the impact on the infant’s swallowing physiology, must be carefully considered and weighed. We have suck a complex job when it comes to supporting safe and neuroprotective feeding. We lack the research to fully guide us, so in addition to evolving research, I think our critical thinking, living in the “grey zone”(having more questions than answers) and dialogue with the medical team are our current optimal strategies.

I hope this is helpful.



Ankyloglossia Resources

Here are some excellent resources for ankyloglossia.  I am also attaching an article regarding why reflux is often an associated co-morbidity. These sites add to our understanding of posterior tongue tie, anterior tongue tie, as well as lip and cheek ties. Dr. Ghaheri has wonderful videos and pictures. I hope these resources inform your practice!

 Assessment Tool for Lingual Frenulum Function developed by Alison Hazelbaker

Siegel 2016 Tongue and lip tie and reflux

Steehler, M. W., Steehler, M. K., & Harley, E. H. (2012). A retrospective review of frenotomy in neonates and infants with feeding difficulties. Int J Pediatr Otorhinolaryngol. doi: 10.1016/j.ijporl.2012.05.00

Teaching at Blythedale Children’s Hospital NY

Just returned from teaching at Blythedale Children’s Hospital in Valhalla, NY. What an amazing program and staff they have, servicing a wide range of children from post-NICU through school age, with multiple complex co-morbidities. The pediatric therapists attending included those from Barcelona Spain and Australia, and we all appreciated the opportunity to problem-solve our patients and service delivery across settings. The grounds are beautiful and covered with animal topiaries that greet the children and their families. My colleague Theresa and I enjoyed their hospitality and the opportunity to share our passion for helping children with feeding and swallowing problems, and their families. Here we are in front of the hospital.

Problem-Solving with Catherine: Rice Cereal does not thicken breastmilk


I have heard that rice cereal is not good to thicken with breast milk. Do you have  research or articles we could use for a discussion with our neonatologists because they prefer we use it as they do not want commercial thickeners at all. We have discussed gel mix but they do not want us to use it. Any suggestions?


The many dieticians I have met have explained it to me as follows. It is the enzymes (such as Amylase, Lipase and Protease). The enzymes in breast milk serve a variety of functions, some of which we do not even know yet. Some enzymes are necessary for the function of the breasts and the production of breast milk, some enzymes help a baby with digestion, and some are essential a child’s development. Amylase is the main polysaccharide-digesting enzyme in MBM and it  digests starch.  So it averts binding of the MBM with rice cereal. Our MDs don’t allow commercial thickeners, either and gel mix is not approved by FDA for preterm in NICU. However some NICUs do.

Doesn’t leave a lot of options so one must look individually with the team at each infant, based on history, whether he can breastfeed (which is typically safer for most preterms unless there is a structural airway problem – and then  breastfeeding  not necessarily more protective). Depending on the etiology of the aspiration, plan will be different. Some infants may have a period of PO feeding formula (which has increased viscosity compared to MBM) or slightly thickened formula with rice cereal – not ideal ever,  but may need to balance multiple factors and utilize as an interim plan related to likelihood of, and timing of,  etiology for bolus mis-direction resolving.

Read more……

Resources for Practice in the PCVICU

One of my SLP colleagues was kind enough to share these excellent resources for those of us who work with infants and children S/P surgery for Congenital Heart Disease. Very informative for my practice.

Pediatric patients with congenital heart defects have their own set of challenges such as heavy amounts of sedation, bypass, pain from surgical incision, and weakness from recovery. A good resource is the National Pediatric Cardiology Quality Improvement Collaborative Website. This group is studying a specific cardiac population HLHS (Hypoplastic Left Heart Syndrome) but there are some good resources. Another website to look for information in regards to neurodevelopment specifically with congenital heart patients is the Cardiac Neurodevelopmental Outcome Collaborative (CNOC) website. These two groups are looking at standard practices in regards to feeding and nutrition. Best practices sometimes come within your unit and your team. Find a physician champion, provide in-services to staff, develop protocols that promote safe and effective feeding practices for your patients. And try to get involved in small research studies or PDSA cycles, (Plan, Do, Study, Act) and share your experiences with other clinicians. Use the basics that you know about feeding safety but be creative with your feeding plans for families when feeding is so important to them.

Research Corner: Dysphagia in infants with single ventricle anatomy following stage 1 palliation: Physiologic correlates and response to treatment


Background: Deficits in swallowing physiology are a leading morbidity for infants with functional single ventricles and systemic outflow tract obstruction following stage 1 palliation. Despite the high prevalence of this condition, the underlying deficits that cause this post-operative impairment remain poorly understood.

Objective: Identify the physiologic correlates of dysphagia in infants with functional single ventricles and systemic outflow tract obstruction following stage 1 palliative surgery.

Methods: Postoperative fiberoptic laryngoscopies and videofluoroscopic swallow studies (VFSS) were conducted sequentially on infants with functional single ventricles following stage 1 palliative surgery. Infants were dichotomized as having normal or impaired laryngeal function based on laryngoscopy findings. VFSS were evaluated frame-by-frame using a scale that quantifies performance within 11 components of swallowing physiology. Physiologic attributes within each component were categorized as high functioning or low functioning based on their ability to support milk ingestion without bolus airway entry.

Results: Thirty-six infants (25 male) were included in the investigation. Twenty-four underwent the Norwood procedure and twelve underwent the Hybrid procedure. Low function physiologic patterns were observed within multiple swallowing components during the ingestion of thin barium as characterized by 4 sucks per swallow (36%), initiation of pharyngeal swallow below the level of the valleculae (83%), and incomplete late laryngeal vestibular closure (56%) at the height of the swallow. Swallowing deficits contributed to aspiration in 50% of infants. Although nectar thick liquids reduced the rate of aspiration (P 5 .006), aspiration rates remained high (27%). No differences in rates of penetration or aspiration were observed between infants with normal and impaired laryngeal function.

Conclusions: Deficits in swallowing physiology contribute to penetration and aspiration following stage 1 palliation among infants with normal and impaired laryngeal function. Although thickened liquids may improve airway protection for select infants, they may inhibit their ability to extract the bolus and meet nutritional needs.

McGrattan, K. E., McGhee, H., DeToma, A., Hill, E. G., Zyblewski, S. C., LeftonGreif, M., … & MartinHarris, B. (2017). Dysphagia in infants with single ventricle anatomy following stage 1 palliation: Physiologic correlates and response to treatment. Congenital Heart Disease.

Read more…Congenital Heart Disease 2017 (Feb 28 epub)

Research Corner: The prevalence and effects of aspiration among neonates with CHD at the time of discharge


Neonates undergoing heart surgery for CHD are at risk for postoperative gastrointestinal complications and aspiration events. There are limited data regarding the prevalence of aspiration after neonatal cardiothoracic surgery; thus, the effects of aspiration events on this patient population are not well understood. This retrospective chart review examined the prevalence and effects of aspiration among neonates who had undergone cardiac surgery at the time of their discharge.

This study examined the prevalence of aspiration among neonates who had undergone cardiac surgery. Demographic data regarding these patients were analysed in order to determine risk factors for postoperative aspiration. Post-discharge feeding routes and therapeutic interventions were extracted to examine the time spent using alternate feeding routes because of aspiration risk or poor caloric intake. Modified barium swallow study results were used to evaluate the effectiveness of the test as a diagnostic tool.

A retrospective study was undertaken of neonates who had undergone heart surgery from July, 2013 to January, 2014. Data describing patient demographics, feeding methods, and follow-up visits were recorded and compared using a χ2 test for goodness of fit and a Kaplan–Meier graph.

The patient population included 62 infants – 36 of whom were male, and 10 who were born with single-ventricle circulation. The median age at surgery was 6 days (interquartile range=4 to 10 days). Modified barium swallow study results showed that 46% of patients (n=29) aspirated or were at risk for aspiration, as indicated by laryngeal penetration. In addition, 48% (n=10) of subjects with a negative barium swallow or no swallow study demonstrated clinical aspiration events. Tube feedings were required by 66% (n=41) of the participants. The median time spent on tube feeds, whether in combination with oral feeds or exclusive use of a nasogastric or gastric tube, was 54 days; 44% (n=27) of patients received tube feedings for more than 120 days. Premature infants were significantly more likely to have aspiration events than infants delivered at full gestational age (OR p=0.002). Infants with single-ventricle circulation spent a longer time on tube feeds (median=95 days) than infants with two-ventricle defects (median=44 days); the type of cardiac defect was independent of prevalence of an aspiration event.

Aspiration is common following neonatal cardiac surgery. The modified barium swallow study is often used to identify aspiration events and to determine an infant’s risk for aspirating. This leads to a high proportion of infants who require tube feedings following neonatal cardiac surgery.

Karsch, E., Irving, S. Y., Aylward, B. S., & Mahle, W. T. (2017). The prevalence and effects of aspiration among neonates at the time of discharge. Cardiology in the Young, 1-7.

 Read more….Cardiol Young 2017 (1-7)