What factors influence early intervention referral for preterm infants?

For NICU-based SLPs, do you find yourself wondering when to consider advocating for an early intervention referral for your littles, especially when they are oh-so-small, high risk, and medically complex? Should the referral be coordinated by the neonatologist or pediatrician on discharge? What factors ultimately play into these decisions?

Martin and colleagues took a dive into this topic to assess timing of referral to early intervention for high-risk infants with bronchopulmonary dysplasia. The authors lament that EI services in the US currently take nearly two months, on average, to initiate following a multi-step referral process after hospital discharge. They wondered:

Does earlier referral lead to earlier initiation and faster time to services for these little ones?

In this study, early referral (defined as 7 days or less post-discharge from the initial neonatal hospitalization), was associated with earlier initiation of services. And factors associated with an EI referral were:

  • Hospital length of stay

    • Those with a longer length of stay received a referral to EI services within 56 days post-discharge compared to those with a shorter length of stay who received the referral 115 days post-discharge.

  • If an infant was discharged with home medical equipment

    • Not surprisingly, infants with medical equipment received a referral significantly quicker than those discharged without medical equipment.

  • Source of the referral

    • Neonatologists were quicker than pediatricians to initiate a referral for EI services.

The study also reports that many families with high-risk infants who are ultimately lost to follow-up (at least 10% according to another study), because they don’t understand the need for EI services.  

What does this mean for us?

We are in a unique position to advocate for these services and educate parents about EI services, even when their little one is still in the NICU. SLPs, along with other members of the neonatal care team, can inform and discuss how each specialty is able to contribute to the development of their child’s skills after the NICU stay and throughout their early years. We play a vital role in parent education and advocacy for relevant early intervention services in speech, language, and feeding development.

Side note: The study also looked at long-term cognitive outcomes for these high-risk infants. Spoiler alert, they found no significant differences in the cognitive skills of infants who received an earlier referral to EI services. But, all patients in the sample did receive EI services and improvements in cognitive scores were seen. The earlier referral for more medically complex infants may have also allowed them to “catch up” to their very slightly less medically complex peers.

Martin, V., Brady, J., Wade, K., Gerdes, M., DeMauro, S. (2019). Timing of Referral to Early Intervention Services in Infants with Severe Brochopulmonary Dysplasia. Clinical Pediatrics. doi: 10.1177%2F0009922819867460

(In)consistency of flow rate during bottle feeds: Any impact on oral feeding in the NICU?

If you’re an SLP practicing in the NICU or a parent of a premature infant, did you ever consider that some feeding difficulties may arise from inconsistencies in the flow rate of nipples? Well, two different studies, independently conducted by researchers in the US and the UK, have identified significant variations in flow rate across trials of commonly used nipples in neonatal care units. These studies were both packed with data and clinically relevant findings.

The studies looked at differences among various nipples from various brands, considering:

  • Disposable and commercially available nipples (and of the same advertised flow type)

  • Nipples marketed similarly to one another (e.g. comparisons between common commercially available nipples all marketed as “extra slow flow” nipples)

  • The impact of pressure on flow rate (i.e. the amount of gravitational pressure pushing fluid out of a nipple)

  • Identification of nipples of comparable flow rates across brands (helpful for parents to more easily select nipples for their infants!)

  • … with multiple trials with the nipples, and with multiple versions of the same nipple

In the Pados et al. study, the authors found that commercially available nipples could be grouped by flow, which often did not align with the brand’s marketed flow rates. Considering data from both studies, they found the following (click out to see!)


What does this mean for infant feeding success?

Both studies identified that each time an infant is fed using the same type of disposable nipple, they will likely receive milk at differing flow rates. This is an external factor that should be considered when assessing an infant’s oral feeding success. Inconsistencies and variations in flow rate can impact acquisition of feeding skills. Compound this with the high likelihood of having different individuals facilitating feeding (in both the NICU and at home), and these babies are experiencing tons of variability! 

Can we do anything to compensate or improve the consistency of flow?

Yes! Both studies suggest that SLPs can work with caregivers and team members to facilitate use of a bottle and nipple that can be used both in the NICU and at home post-discharge, for a more stable path to successful feeding. Also:

  1. Carefully inspect the disposable nipples prior to use. Quality inconsistencies were present due to missing holes or silicone sticking to itself, causing flow to be blocked. Pados et al. (2019) notes that if the infant appears to be sucking well but not extracting fluid, this may the cause.

  2. Don’t overtighten the collar on bottles because this can interfere with venting systems and cause nipple collapse, which might be misinterpreted by the feeder as the nipple having too slow of a flow for the infant. 

  3. Consider how hydrostatic pressure impacts flow rate. This doesn’t usually impact healthy, typically developing infants, but infants in the NICU are more susceptible to this. To combat this, the data from Pados et al. (2019) suggests that clinicians should only put the minimum amount of fluid in the bottle that is needed for the feeding session. Excess fluid and gravity increases flow rate.

    Side note: This also adds support for use of a sidelying position for these infants as well (the horizontal bottle that results from a sidelying position can also reduce hydrostatic pressure during the feed and slow flow rate). 

  4. When recommending nipples for home use, select brands that have a lower variability in flow rate.


Bell, N., & Harding, C. (2019). An investigation of the flow rates of disposable bottle teats used to feed preterm and medically fragile infants in neonatal units across the UK in comparison with flow rates of commercially available bottle teats. Speech, Language, and Hearing. doi: 10.1080/2050571X.2019.1646463 (UK Study)

Pados F, Park J, Dodrill P. (2019). Know the Flow: Milk Flow Rates From Bottle Nipples Used in the Hospital and After Discharge. Advances in Neonatal Care. doi: 10.1097/ANC.0000000000000538 (US Study; more from their lab, here)

What if SLPs always did a feeding evaluation before infant frenotomies?

How often do you find yourself completing an infant feeding evaluation and find that the baby has already had a frenotomy? Or maybe a parent says, “I’ve had people say that my baby is tongue tied, but I’m not really sure if that’s her problem or not.” Often, tongue and lip ties are mentioned in the context of breastfeeding and while we do know that parents often report improvement in breastfeeding following frenotomy, it’s also not the only cause of feeding difficulties in infants, making it necessary to look at factors such as milk supply, GI dysfunction, state regulation, or pharyngeal dysphagia.

In a study by Caloway, et al., infants who were referred to an otolaryngologist (ENT) for frenotomy first underwent a clinical feeding evaluation by an SLP to figure out which factors were contributing to the infant’s feeding difficulty. The SLP subjectively assessed nonnutritive and nutritive feeding skills, took mother and infant history, and used several formal measures with each patient:


The SLPs provided education and interventions based on the feeding deficits identified. Parents trialed these interventions for the days leading up to the surgery appointment, and at the surgery appointment, the ENT considered the results of the SLP evaluation and effectiveness of the feeding interventions before proceeding with the frenotomy (labial, lingual, or both). In the six months prior to utilizing SLP clinical feeding evals as part of standard procedure, this ENT had performed a frenotomy on more than 95% of patients referred. But after SLP evaluation and strategies were incorporated—only 37% were recommended for the frenotomy! The study authors didn’t collect long term follow up-data to determine how successful infants and their families were after the clinical feeding evaluation (and possible frenotomy), but such a large drop in how many infants were judged to truly need the frenotomy (after all, they were referred for frenotomies) is noteworthy.

So what were those feeding interventions that made such a difference? Check out the methods section see which strategies were used to target improved positioning, latch, and flow rate, among other things. And while you’re at it, listen to a short interview with one of this paper’s authors!


Caloway, C., Hersh, C. J., Baars, R., Sally, S., Diercks, G., & Hartnick, C. J. (2019). Association of Feeding Evaluation With Frenotomy Rates in Infants With Breastfeeding Difficulties. JAMA Otolaryngology–Head & Neck Surgery. doi: 10.1001/jamaoto.2019.1696

What’s the likelihood of having a surgery for tongue tie, anyway?

Diagnosis and management of tongue tie, or ankyloglossia, is currently a hotly debated topic. Due to this, both clinicians and families often report increased frustration trying to tease out the most appropriate management route. Provider philosophies frequently differ on the significance of indications for treatment of ankyloglossia. And it’s not just ENTs whose opinions differ. A lack of standardized practice guidelines doesn’t help the matter much either. Turns out, there is a significant difference in the rate of frenotomy (the surgery used to release a tongue tie) across ENTs who treat ankyloglossia.

So, what’s a clinician to do? Is there anything we can all agree on when it comes to a tongue tie?

Authors of this study sought to determine what variables impacted the likelihood of a child having surgical intervention to release a tongue tie. Authors completed a three-year, retrospective chart review on the records of 266 children less than a year old who had been diagnosed with ankyloglossia. All providers in this study were fellowship-trained, pediatric otolaryngologists. Study groups were divided by ENTs who performed frenotomy on more than 50% of patients with ankyloglossia compared to ENTs who performed frenotomy on less than 50% of patients with ankyloglossia.


The variables considered: providers involved in the assessment, referral source, insurance type, race, age, sex, primary language of caregivers, prior lactation consultation, location of frenotomy, and patient prematurity status. Referral source, insurance type, and race were not associated with frenotomy (good news there).  

Age and sex were associated with higher frenotomy rates. Authors found frenotomy occurred more often in younger patients (2.6 months vs. 3.5 months) and more often in males. In the sample, male children had 2.5 times greater likelihood of receiving surgical management than female children. Also, the younger the patient was when recommended for frenotomy, the more likely they were to receive the procedure in the office rather than under general anesthesia in the operating room. This makes sense, given that the decision to anesthetize an infant must be weighed prior to any procedure.

A lactation specialist consultation was associated with lower rates of frenotomy, but this association disappeared when the authors controlled for age, gender, and ENT.  What might this variable tell us? Functional assessment is crucial. As one of our reviews from last month points out, “when you are assessing tongue tie, tongue function is much more relevant than the appearance of the frenulum.” 

Overall, the study suggests some subjective differences in management may exist and highlights the lack of consensus among ENTs in the literature. Differences behind an individual ENT’s rationale for completing frenotomy or not completing frenotomy are yet to be determined.

We are still learning about when and why frenotomies are performed, and if they are necessary. Trends may indicate that function over form is key here, and this is becoming something we can all agree on.


LeTran V, Osterbauer B, Buen F, Yalamanchili R, Gomez G. (2019). Ankylglossia: Last three-years of outpatient care at a tertiary referral center. International Journal of Pediatric Otorhinolaryngology. doi: 10.1016/j.ijporl.2019.109599

“There was definitely improvement on this swallow study. At least…I’m pretty sure there was?”

This review is published in our Preschool & School-Age section as well.

Treating children who have documented aspiration or deep penetration on an instrumental swallow study (like a modified barium swallow study or MBS) can leave you wanting more objective information on a regular basis. You might request another MBS because the child has started to decline due to a chronic or progressive condition. Or, maybe you’re hoping to see if there’s been any improvement following a surgical procedure or treatment approach! This kind of progress monitoring can be hard to do because pediatric swallow studies are rarely protocol-driven in the way that adult studies can be. (You inventive SLPs who sweet talk your way, literally, through a swallow study with a nervous preschooler by alternating each presentation with a barium-covered gummy bear know what I’m talking about!)


If you know much about adult dysphagia, you’ve probably heard of the Penetration-Aspiration Scale (PAS). It’s an eight point scale used to quantify how deep into the airway a bolus reaches (if at all) and if it stays there after the swallow is completed. The PAS has been widely used in the adult world, but Wick et al. wanted to know how well the PAS would carry over to pediatric populations by looking back at medical records and MBS recordings of thirty children. And good news! By having multiple SLPs review performance on the swallow studies, they found that the PAS had outstanding intrarater reliability (do your ratings match if you look at the same swallow twice) and excellent interrater reliability (does your colleague’s rating match yours if you both look at the same swallow) in the pediatric population. And remember reliability’s best friend, validity? (Meaning: Does the test actually measure what it says it measures?) Authors compared changes in PAS scores (using each patient’s worst thin liquid score)with successful diet advancement for each patient at the time of the follow up MBS and found that the PAS did demonstrate good construct validity, even in this group of young children. In other words, PAS scores improved as the diet recommendations provided at the time of the second MBS advanced. A scale that’s reliable, valid, and easy to implement—it’s a good one to have around!

Oh—why were the patients in this study getting repeat MBSs, anyway?

These children had all undergone a procedure called interarytenoid injection augmentation (IAIA, essentially an injection to build up the interarytenoid space). Some of these children had a type 1 laryngeal cleft diagnosed during a laryngoscopy, while others had unexplained persistent pharyngeal dysphagia. Our understanding of why IAIA works to prevent aspiration in this second group (the ones without an identifiable laryngeal cleft) is still limited, but it’s probably worth chatting with your friendly ENT about. Note that only about half of the patients here were reported to have improved swallowing outcomes after IAIA, and the only demographic difference between those with and without improvement was the number of comorbidities. Read the introduction section of this study closely if you’d like a mini-primer on type 1 laryngeal clefts and IAIA.

Wick, E. H., Johnson, K., Demarre, K., Faherty, A., Parikh, S., & Horn, D. L. (2019). Reliability and Construct Validity of the Penetration-Aspiration Scale for Quantifying Pediatric Outcomes after Interarytenoid Augmentation. Otolaryngology–Head and Neck Surgery. doi: 10.1177/0194599819856299