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Case Studies in Pediatric Dysphagia
Jennifer J. Wilson
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Wilson
CASE STUDIES
Through clinical cases and interviews with working professionals, Case Studies in Pediatric
Dysphagia takes an original approach to understanding pediatric dysphagia. This text,
designed to address the increased need for clinical education, covers topics such as
differential diagnosis, medical terminology, and goal setting. Written with group interaction
and collaboration in mind, the book provides role-play scenarios, suggestions on how to in
Pediatric
delve deeper into the case studies, integrating interprofessional practice, and evidence-
based treatment approaches. Each chapter includes a case study and a detailed interview
with a pediatric dysphagia professional, providing a complete and thorough view of the
topic in a reflective and practical way.
Key Features:
Dysphagia
CASE STUDIES in Pediatric Dysphagia

• Provides increased opportunities for students and young professionals to
gain experience with complex clients before engaging in intervention
• Gives guidance for integrating interprofessional practice as it relates to
pediatric dysphagia
• Written to prompt the reader to shift toward implementation science, merging
research and clinical practice to better serve patients with pediatric dysphagia Jennifer J. Wilson
• Informative interviews with specialists working and conducting research in the field
• Offers additional resources at the end of each chapter for the reader to continue their
learning on specific case areas of focus
• Provides a deeper understanding of cultural considerations and how to incorporate
them into practice patterns
• Allows students and professionals to integrate both diagnosis and treatment choices
and explores current evidence-based approaches to treatment
Both speech-language pathologists and clinical educators will benefit from having this
valuable resource on their bookshelves.
Jennifer J. Wilson, MA, CCC-SLP, BCS-S, is a Clinical Assistant Professor

in Speech Pathology at the University of Tennessee Health Science
Center. She has been practicing for 30 years, providing services in
children’s hospitals, private practice, and home-based services. She
enjoys teaching graduate students and young professionals about
pediatric dysphagia through use of case studies to develop skills in clinical
problem solving.
www.pluralpublishing.com
CASE STUDIES
in
Pediatric Dysphagia
CASE STUDIES
in
Pediatric Dysphagia
Jennifer J. Wilson, MA, CCC-SLP, BCS-S

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San Diego, CA 92123
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Library of Congress Cataloging-in-Publication Data:
Names: Wilson, Jennifer J. (Speech-language pathologist), author.

Title: Case studies in pediatric dysphagia / Jennifer J. Wilson.
Description: San Diego, CA : Plural Publishing, Inc., [2023] | Includes
bibliographical references and index.
Identifiers: LCCN 2022056083 (print) | LCCN 2022056084 (ebook) | ISBN
9781635503975 (paperback) | ISBN 1635503973 (paperback) | ISBN
9781635503982 (ebook)
Subjects: MESH: Deglutition Disorders--diagnosis | Deglutition
Disorders--therapy | Deglutition--physiology | Diagnosis, Differential |
Infant | Child | Case Reports | Interview
Classification: LCC RC815.2 (print) | LCC RC815.2 (ebook) | NLM WI 258 |
DDC 616.3/23--dc23/eng/20230130
LC record available at https://lccn.loc.gov/2022056083
LC ebook record available at https://lccn.loc.gov/2022056084
Contents
Introduction vii
Acknowledgments xv
Interviewees xvii
Reviewers xix
Chapter 1. Differential Diagnosis in Pediatric Dysphagia 1
Chapter 2. Genetic Syndromes 27
Chapter 3. Aerodigestive Management of Swallowing 57

Disorders
Chapter 4. Gastrointestinal Diagnoses 79
Chapter 5. Trauma-Informed Care 105
Chapter 6. Pulmonary Diagnoses 135
Chapter 7. Traumatic Brain Injury 161
Chapter 8. Ethical Considerations 179
Conclusion 199
Index 201
v
Introduction
It’s March 2020. The week before there was speculation, but I received
the email notifying me that the University of Tennessee was closed due to
COVID-19. Suddenly, it was time to get “up to speed” on how to do clinical
simulations and teletherapy.
I contacted Plural Publishing and asked for permission to use the
case studies in Pediatric Swallowing and Feeding by Arvedson, Brodsky,
and Lefton-Greif. I had read these case studies during my lunch break
every day as I was preparing for the American Board of Swallowing and
Swallowing Disorders exam. They were challenging, but the thing I loved
about them was the stories that they told. The journey began.
As clinical faculty, we were learning the clinical simulation process
quickly. Through Simucase, we were introduced to new terms, like debrief.
I wrote up a protocol for the case studies as simulation tools and the
meetings began.
First, the students were sent case studies to read independently. Next,
either one-on-one or small group meetings began. It was a front-porch
clinical simulation at its finest. Students read the case studies out loud,
learning how to attack the new terms. After each paragraph, we stopped
and rehashed what had been read. How old was the child? What would
we expect developmentally at this age?
As the cases unfolded, the layers of the story emerged. Students were
able to imagine parental perspectives, role-play relaying results of modi-
fied barium swallow studies, and discuss oral sensorimotor findings. As we
began doing the cases, previous cases came to mind. I shared anecdotal
stories. Connections were made through bringing these cases to life that
were different from any supervision experience I had provided.
We spent time talking about what we had learned and what thera-
peutic approaches might have been good to try if you had seen that client
for therapy. The takeaways from each case helped provide a sense that
others’ perspectives were taken, new terms were learned, and skills in
professional discussion were developing in these students.
A few months later, the university clinic reopened. The in-person
cases slowly started again. However, I knew that I had been changed as a
supervisor. I was inspired to open a dialogue about differential diagnosis,
vii
viii CASE STUDIES IN PEDIATRIC DYSPHAGIA
assessments, and referrals, considering that every case in pediatric dys-

phagia was unique.
I was also ready to have conversations about intervention. There is
so little empirical evidence to support pediatric dysphagia intervention.
This population is so difficult to research because each case is so unique.
I wanted to begin to “talk about the elephant in the room.”
We are always talking about how there is so little research, but the
bottom line is these children can’t wait for the research. We must do the
best that we can for them with deep learning regarding oral and pharyn-
geal anatomy and physiology and rely on our medical counterparts to
support our intervention. We need to spend some time talking with each
other and listening carefully. We need to encourage a culture of wisdom
and experience through mentorship.
Each chapter culminates with an expert interview. Some were research-
ers, and some were experienced clinicians. The strides they have made
for our profession through research and intervention are incredible. The
perspectives shared were so varied and provided so much more depth
than I would have ever imagined. I am so grateful to the professionals
who helped us understand research, unique training, and future directions
of our profession.
The book content won’t be timeless. Studies will be completed so
research findings can be applied. Technology will improve the way that
we evaluate and treat. Yet, discussions sharpening our ability to provide
the best care for our patients can move us forward as clinicians.
Introductory Interview
Rebecca Smith, MS, CCC-SLP, CNT, is a clinical educator/adjunct instructor.

She is a Certified Neonatal Therapist, Voice and Dysphagia at Appalachian
State University. She is also pursuing her clinical doctorate.
Jennifer Wilson ( J): Tell us about your current work in pediatric

dysphagia.
Rebecca Smith (R): I work in a medical focus university-based clinic
in a rural community. I see a lot of variety throughout my day. I’m
working toward developing an infant and pediatric feeding and swal-
lowing program in the clinic.
To do that, I have been focused on making sure that I am myself
up to date in evidence-based practice patterns. I want to make sure
that I am using the best patient-reported outcome measures, that
I’m making connections with providers in the area, and that I’m also
ix
INTRODUCTION
supplying resources to students. A lot of them receive little pediatric

dysphagia-focused coursework in their graduate programs. Our uni-
versity is different in that we do have an elective pediatric dysphagia
course that they can take. I’m planning on teaching in the fall. I’m
developing that coursework and planning. It’s tying together nicely
for my interest.
J: You are also working on developing your dissertation, right?
R: In this process of developing my research interests, I began real-
izing how teaching and research were coming together as I was
developing this program in the clinic. I talked to mentors in the fields
who have done similar things at their university-based clinic, people
in the field of pediatric dysphagia I really respect. They all commonly
were telling me about the infant child feeding questionnaire tool as
developed by Feeding Matters. They expressed the importance of
making sure that I’m capturing the four domains of pediatric feeding
disorder in my intake paperwork for patients and then also in my
evaluations and making sure that I’m educating students about them.
Getting that consistency in talking to people, this sparked an interest
in looking more at, “Do providers understand the four domains of
pediatric feeding disorder as established by Goday et al. consensus
paper, with support from Feeding Matters. What are providers cur-
rently doing now to show patients with disordered feeding? If they’re
given education on the four domains and introduced to the six-item
screening tool that was developed by Feeding Matters and colleagues,
where if there’s two or more positives on the screening tool, then it
is indicative of a need for a possible referral to feeding specialists,
will that result in early identification of pediatric feeding disorder?
Will it result in a change of practice? How will increased awareness
be reflected in their clinical practice patterns?” I think just really
marinating on those thoughts helped me focus my research interests
and as I’m developing my dissertation. I know that I’m going to have
to narrow that significantly just for the purposes of getting my PhD
finished but I see myself continuing in this line of research.
J: Talk a little bit about your earlier work leading up to your transition
now into the academic world.
R: Most of my clinical background was in acute care, specifically in
the neonatal intensive care unit. I also did objective swallow studies
for outpatient pediatrics. Patients would come to the hospital to get a
study and then they would go back to their clinic. They were treated
by whoever referred them for this study. I really enjoyed the hospital
x CASE STUDIES IN PEDIATRIC DYSPHAGIA
setting. I enjoyed the variety of my day and the pace, but I felt that
in my next position, I wanted to make a different kind of difference.
J: Talk about how you made that transition from a community hospital
to the university-based clinic.
R: I was at a point in my career where my interest was moving toward
investigating best practice and how to best educate students in my
area of clinical interest. That led me to start a PhD program. I was
thinking, I’m in this program, I want to go somewhere that would
support me and continuing this academic journey, a place that’s going
to have the resources for me to do the research that I want to do
and be able to measure change in students’ learning. The hospital
certainly was supportive of me getting my PhD, but it wasn’t really
something that I would have used there in the clinic and then clinical
setting at the hospital because it wasn’t a university-based hospital or
it was a community hospital and, in that setting, I was able to make
connections in the community. It gave me the opportunity to educate
more generic providers on specialty services like talking a lot about
trauma-informed care in the NICU (neonatal intensive care unit) and
how to provide counseling and communicating with patients and
families that are in a vulnerable stage in their disease journey. They
taught me a lot of important things but ultimately when I was inter-
ested in continuing with my career, I was ready to make a change.
J: Tell me about your academic training in pediatric dysphagia.
R: My graduate program I thought was a great program, but I left it
with little knowledge of pediatric dysphagia and even less knowledge
of infant feeding. I think that was partially because of the rurality of
our program. Also, it was several years ago, and I feel like pediatric
dysphagia was just covered as a part of the regular dysphagia course-
work, which truthfully is how it is in a lot of places still now. I think
that there is more of an emerging recognition of the need for more
education, and we need to talk about it more. I think that now courses
often include more sessions on pediatric dysphagia.
J: Post graduate school, what have been some strategies for you that
you have used in getting skills in pediatric dysphagia?
R: For neonatal practice, I went to work at a large university-based
hospital and that was a requirement of mine to work there, to be
trained in the NICU. I didn’t know anything about it. I was willing
to learn, and they had a set of competencies that I was expected to
achieve through continuing education and reading of research and
then completion of skills check-offs. When you’re fortunate enough
xi
INTRODUCTION
to be in a situation like that where someone is handing you what

you’re supposed to know, it makes your learning journey a lot easier.
J: Have you talked to other speech pathologists about similar
experiences?
R: I can tell you that most people are not in that situation. They take
over a caseload in their CFY (clinical fellowship year) and a lot of
times their CFY supervisor is not well versed in that subject. I know
several former students who are experiencing that in their pediatric
feeding disorder caseload.
J: Talk about how we can continue to grow and learn as feeding and
swallowing specialists.
R: Even here at this university-based clinic, I’m really the first person
that has had these research and clinical interests. I’ve had to really
take responsibility for my own learning in a way that a lot of other
people have many times before me. I am currently doing that through
reading research, setting up mentors in the field (that was huge for
me), and then taking sound continuing education courses. I think this
is most challenging in pediatric dysphagia because there are so many
types of courses that aren’t necessarily grounded in evidence. You
really must be a consumer of literature and surround yourself with
people you trust to further your own education. I feel like I’ve done
that where I’m now because I had a lot of diagnostic background
but maybe not as much treatment background. I find myself taking
coursework and really reading literature, speaking to occupational
therapists, speaking to other people in the field who have a lot of
knowledge about growth and fine motor development, neural devel-
opment. In pediatric feeding disorder, you must look at everything,
not just one piece of the puzzle.
J: Talk a little bit about challenges that feeding and swallowing spe-
cialists face in rural areas.
R: Well, I think there are a lot of challenges. I talk to my peers about
that a lot. I think one of the biggest challenges that I face now is that
there are a lot of pediatricians but not as many pediatrics specialties
services such as GI (gastrointestinal), pediatric ENT (ear, nose, and
throat). There are a lot of providers in town who are generalists.
They must see a lot of different things because they just don’t have
the ability to specialize as much as they might like. There is a lack
of provider presence. Oftentimes, when we need our patient to see
pediatric GI, we must refer them to a place that’s a couple of hours
away. Transportation can often be an issue for these patients with
xii CASE STUDIES IN PEDIATRIC DYSPHAGIA
weather-related issues and travel expenses. Getting an appointment

is a problem sometimes. Some of these patients just can’t afford to
wait. That is a huge barrier.
Access to instrumentation can be a problem. It’s not a problem
for me. I’m fortunate about that but it is for some places that are rural,
and I think that the lack of communication between specialty provid-
ers and the clinician that ends up seeing the patient in their rural
hometowns can be a challenge. They don’t always get all the report
information. They don’t really know what happened because they
didn’t go with the patient to the hospital and watch the instrumental
study. Oftentimes, people in small private practices who are treating
patients for pediatric feeding disorder have funding issues. There are
ways to circumvent that if you educate yourself. They just must work
a little bit harder in providing an evidence-based practice that is also
possible and financially helpful.
We have a good amount of access to supplies. I feel fortunate.
Not all home health practitioners have everything they need. Some-
times parents are the ones that must advocate for their children’s
medical supplies, but they don’t even know where to begin. You can
feel really disconnected I think in rural areas.
J: How do you feel that we can bridge the gap between clinical work
and research in pediatric dysphagia?
R: A wonderful way to bridge the gap would be for there to be more
individuals interested in pediatric dysphagia in academia. I think that
would be a fantastic way to start bridging that gap. Also, for there
to be more of a specific course and clinical rotation-based focus
in pediatric dysphagia for those individuals who are interested in
pursuing that after graduation. Involving the students in research
because they’re often excited to have opportunities to be involved in
projects like that. That would be a wonderful way. Even those in aca-
demia who do not specialize in pediatric dysphagia could still create
working relationships and research relationships with clinicians who
also work in the field and who are not necessarily connected to an
academic institution who have a research interest. I know of several.
They don’t have an academic background or they’re not currently
pursuing a terminal degree, but they’re super interested in contribut-
ing to research. I think to get that going, they often need a connection
to someone at an academic institution.
R: There are some who don’t work directly for a specific university,
but they work in teaching-based hospitals and are given research
time but that is the exception not the rule. Most people, like myself,
if I was going to be contributing to research in infant child feeding
xiii
INTRODUCTION
and swallowing when I was still at my last hospital, that would have
been something I would have had to do on my own time. I wouldn’t
have had time in my day to really do that. It’s simply hard for people
to have a research interest, a full clinical load, and then keep any kind
of work-life balance.
I struggle with it. I’m doing a little better here just because I have
more flexibility in my schedule than I did when I was in the hospital.
It’s a problem that we talk about a lot, but there doesn’t seem to be
a lot of solutions for it, at least one that’s easy.
I think that pediatric dysphagia specialists who are in academia
need to step up in their contributions to research. So many clinicians
are waiting for some of the methods they use to be validated. There’s
just such a lag in generating evidence-based creation of treatment
practices and evaluation methods in this patient population and a
lack of actual validation of those methods. Because of that, I think it
creates a lot of polarization in choosing specific modalities and it’s
very confusing for new graduates where to go. I think a lot of it starts
with people in academia asking questions and getting the data that is
needed for clinicians to feel like they’re choosing the best evaluation
and treatment approaches. That can’t really happen until people in
academia step up and do more studies.
J: I love the way you were so transparent there about how it can feel
uncomfortable as a recent graduate when you’re wanting to follow
evidence-based practice and you really must rely so heavily on clini-
cal judgment. In that triad, that’s really where we are in pediatric
dysphagia and put that pressure on young clinicians that recently
graduated who don’t have a lot of clinical experiences is a precarious
position, isn’t it?
R: It is and they’re more likely to get a job in pediatric and feeding
and swallowing-based programs than they are in adult dysphagia,
truthfully. Most home health, EI (early intervention), and private prac-
tice, places like that are what’s going to hire these new clinicians,
because there’s such a shortage. They don’t have a knowledge base
and it’s very scary for them. I also think that clinicians must challenge
themselves. Researchers must rise to the occasion of doing more
research in this area if they are able to do so. Clinicians must step up
and read what little research on specific methods and find mentors
and they must do things like that to achieve the best outcomes for
their patients. They should never really be in a place where they’re
doing the same thing as 10 years ago that they’re doing today.
Acknowledgments
I am deeply appreciative of the many mentors throughout my academic

and professional training who directed me progressively toward pediatric
dysphagia. It began with education. Here are some educators whose words
shaped my clinical practice: Dr. Marilyn Newhoff, Dr. Patricia McCarthy, Dr.
Carol Swindoll, Dr. Joel Kahane, Ms. Alicia Ashcraft, and Ms. Sallie Hillard.
As a clinical fellow, I continued to find mentors in Dr. Jeri Logeman, Dr.
Monica Wojick, Mr. Robert Beecher, Dr. Joan Arvedson, and Dr. Miriam
Weinstein. There are countless others who continue to shape my practice.
Thank you to so many who provided advice and direction during
this project. Dr. Devin Casenhiser helped shape the text format through
his suggestion about interviews with leaders in the field. Susan Tucker
provided insight into the best way to edit the interviews to improve their
readability. My children and grandchildren, Wyeth, Eli, Ella, and Jackson,
provided me with better insight into pediatric dysphagia than any other
professional experience. Most important, my husband Danny Wilson spent
countless hours providing illustration/design and an ear to bend through-
out the editing process.
xv
Interviewees
Denise Chapman, MS, CCC-SLP

Speech-Language Pathologist
Monroe Carell Jr. Children’s Hospital at Vanderbilt
Nashville, Tennessee
Memorie Gosa, PhD, CCC-SLP, BCS-S

Associate Professor and Chair
Communicative Disorders
The University of Alabama
Tuscaloosa, Alabama
Katlyn Elizabeth McGrattan, PhD

Assistant Professor
Department of Speech-Language-Hearing Sciences
University of Minnesota
Minneapolis, Minnesota
Heidi Liefer Moreland, MS, CCC-SLP, BCS-S, CLC

Clinical Coordinator
Thrive Tube-Weaning Program
Alexandria, Virginia
Rebecca F. Smith, MS, CCC-SLP, CNT

Clinical Educator/Adjunct Instructor
Department of Communication Sciences and Disorders
Appalachian State University
Boone, North Carolina
Miriam Weinstein, MD
Physical Medicine and Rehabilitation Specialist
University of Tennessee Health Science Center
Memphis, Tennessee
xvii
xviii CASE STUDIES IN PEDIATRIC DYSPHAGIA
Emily Wojtowicz, MS, RD, CSP, LD, IBCLC

Doctoral Candidate, Community Nutrition
University of Tennessee
Knoxville, Tennessee
Robert Yost, CRT

Certified Respiratory Therapist
East Tennessee Children’s Hospital
Knoxville, Tennessee
Emily Zimmerman, PhD

Associate Professor
Communication Sciences & Disorders
Northeastern University
Boston, Massachusetts
Reviewers
Chelsea Bell, MA, CCC-SLP

Pediatric Feeding Specialist
Chelsea Bell SLP, LLC
Denver, Colorado
Christopher Bolinger, PhD, CCC-SLP

Assistant Professor
Texas Woman’s University
Denton, Texas
Allison Tidwell Brown, MS, CCC-SLP, BCS-S

Children’s Health Medical Center
Dallas, Texas
Lori Caplan-Colon, MS, CCC-SLP

Founder of Montclair Speech Therapy
Montclair, New Jersey
Melissa Carrier-Damon, MA, CCC-SLP, BCS

Program Development Manager/Speech-Language Pathologist
American Board of Swallowing and Swallowing Disorders
Jamie Fisher, PhD, CCC-SLP

Adjunct Professor
Western Kentucky University
Bowling Green, Kentucky
Laura H. Loveless, MS, CCC-SLP, BCS-S, CLC

Texas Children’s Hospital
Houston, Texas
xix
xx CASE STUDIES IN PEDIATRIC DYSPHAGIA
Jenan Maaz, MS, CCC-SLP, CBIS

Acute Care Speech-Language Pathologist
Doctor of Speech-Language Pathology Candidate at Northwestern
University
Towino Paramby, CScD, CCC-SLP, BCS-S

Associate Professor
University of Central Arkansas
Conway, Arkansas
Julie Raplee, MS, CCC-SLP

Assistant Professor and Chair
St. Joseph’s University
Brooklyn, New York
Shannon W. Salley, SLPD, CCC-SLP

Assistant Professor
Longwood University
Farmville, Virginia
Bonnie K. Slavych, PhD, CCC-SLP, ACUE

Assistant Professor
Missouri State University
Springfield, Missouri
Karin Thomas, SLPD, CCC-SLP

Assistant Professor
Saint Mary’s College
Notre Dame, Indiana
Jan Traughber, EdD, CCC-SLP

Associate Professor
Harding University
Searcy, Arkansas
1
Differential Diagnosis
in Pediatric Dysphagia
INTRODUCTION
Pediatric feeding disorder (PFD) has been defined as impaired oral intake
that is not age appropriate and is associated with medical, nutritional, feeding
skill, and/or psychosocial dysfunction (Goday et al., 2019) (Figure 1–1).
Recent incidence data provide an estimate of the annual incidence of PFD
in the United States to be between 1 in 23 and 1 and 37 for children under
5 years of age. The incidence for children under 5 years of age with chronic
diseases was between 1 in 3 and 1 in 5 (Kovacic et al., 2021).
As PFD becomes more clearly defined and there is more clarity about
an increased incidence, organizations like Feeding Matters and Dysphagia
Research Society have helped provide networking and resources to pro-
fessionals engaged in research, education, and intervention of pediatric
Medical Nutrition
Feeding skill Psychosocial
Figure 1–1. Four key domains associated with

pediatric feeding disorder.
1
2 CASE STUDIES IN PEDIATRIC DYSPHAGIA
dysphagia (Dysphagia Research Society, 2022; Feeding Matters, 2022). Evalu-

ation tools to better screen and evaluate skills have been introduced and
assessed for test-retest reliability (Silverman et al., 2020; Thoyre et al., 2018).
However, the literature to support feeding and swallowing interven-
tion has not emerged in alignment with these other advancements. In
their 2016 article, “Pediatric Feeding/Swallowing: Yesterday, Today, and
Tomorrow,” Lefton-Greif and Arvedson (2016) postulate that the oral-
motor and sensory-based intervention strategies used in treatment lack
evidence-based support in the literature. As the literature is combed, this
point has resonated repeatedly. Oral and pharyngeal treatment studies are
characterized by limited sample sizes, diverse populations, and differing
intervention techniques.
The need for further research was also a common point of discussion
throughout the expert interviews of this text. While the framework is laid
to better guide intervention, a scoping review revealed gaps in research
of pediatric feeding disorder. Another gap mentioned was limited to first
authorship in the domains of feeding skill and nutrition. Authors also cited
that though research is occurring, it is not well represented in non-Western
countries (Estrem et al., 2022).
Before grappling with the lack of evidence to support intervention,
feeding and swallowing specialists should be trained in clinical reasoning.
Researchers cite that the use of treatment strategies should be supported
through applying scientific therapy practice (Gosa & Dodrill, 2017).
Another good place to start is by having a firm foundation of knowledge
in normal feeding and swallowing (Figure 1–2).
As more studies emerge regarding normal feeding and swallowing
skills at specific ranges of development (Delaney et al., 2021), further
support will be in place to guide intervention practices with this hetero-
geneous population. More information about cultural differences must be
considered (Hall & Johnson, 2020). Gaining more data about parent and
caregiver roles in development and intervention must also be researched.
Evie’s case study provides a window into the complexities of diag-
nosing feeding skill issues, managing a multifactorial case (e.g., potential
gastrointestinal issues, lack of caregiver consensus), and understanding
DEVELOPMENTAL STAGES IN INFANT AND TODDLER FEEDING

https://infantandtoddlerforum.org/media/upload/pdf-downloads/3.5_
Developmental_Stages_in_Infant_and_Toddler_Feeding_NEW.pdf
FEED YOUR BABY & TODDLER RIGHT: EARLY EATING AND
DRINKING SKILLS ENCOURAGE THE BEST DEVELOPMENT
Author: Diane Bahr, MS, CCC-SLP, CIMI
Figure 1–2. Supplemental resources to learn more about normal

feeding and swallowing skills.
1. DIFFERENTIAL DIAGNOSIS IN PEDIATRIC DYSPHAGIA 3
the importance of caregiver education and communication in managing

acute issues (e.g., spitting out food, refusing food).
Evie lived in two different housing environments during treatment.
She lived with both her foster parents and had increased visitation with her
biological mom. The potential for lack of health equity for Evie was consid-
erable given the differences between the two environments. Throughout
the intervention, there was increased time spent with her biological mom.
These transitions and the lack of reporting from her biological mom make
it difficult to determine her response to intervention.
Following the case study, Dr. Katlyn McGrattan discussed the impor-
tance of considering swallowing physiology in determining our course of
intervention. She drove home the point that we must use the best evidence
available through a thorough understanding of anatomy and physiology.
She also stressed the importance of relying on a team of professionals.
CASE STUDY: EVIE
Case Study Medical History
Episode 1: Evie was referred for outpatient services at 9 months of age

adjusted due to difficulty transitioning to solid foods. (See Figures 1–3 and
1–4 for images of a 9-month-old and 3-month-old.) Both her foster mother
and biological mother were present and provided relevant information.
Figure 1–3. Nine-month-old. Figure 1–4. Three-month-old.

She was the product of a 27-week gestational pregnancy with a

birthweight of 2 pounds and 12 ounces. Prenatally, she was exposed to
methamphetamine, heroin, oxycodone, marijuana, and tobacco use. Her
birth mother was also positive for hepatitis C. At birth, Evie was diagnosed
with jaundice. She was later diagnosed with bronchopulmonary dysplasia.
One minute after birth, Evie’s APGAR score was 6, and 5 minutes after
birth, her score was 8.
She passed her hearing screening bilaterally. A follow-up was needed
at 9 months, which she also passed. She remained in the neonatal intensive
care unit (NICU) for 4 months.
In terms of developmental milestones, Evie was reported to sit unsup-
ported at 8 months adjusted and crawled at 9 months adjusted. During
the evaluation, she stood and walked while holding onto supports (e.g.,
table, caregiver’s hand). Speech and language milestones did not occur
as expected. Babbling and the emergence of jargoning had not been
observed. Evie made few sounds during the evaluation other than open
vowel productions.
Feeding and Swallowing History: Evie was not breastfed and required
formula changes. Her first bottle was given at approximately 3 to 4 months
old unadjusted in the NICU. She was given cereal at 6 months adjusted,
but she frequently spit it back up. Foster mom stated that “Evie has issues
swallowing and controlling her tongue.” (See Figure 1–5 for information
Age Range Oral Motor Action

4 to 6 months Introduction of cup
6 to 8 months Suckling pattern for liquid intake from cup; wide jaw
excursions; liquid loss
8 to 12 months Sucking pattern for liquid intake; up-and-down jaw
excursions; tongue may protrude underneath cup to provide
stability for sucking; liquid loss during intake
12 to 18 months Sucking pattern for liquid intake; may bite down on cup to
gain jaw stabilization; upper lip closes on edge of cup for
seal while drinking; less jaw excursion while drinking
18 to 24 months Use of a more mature up-and-down sucking pattern; cup is
held between the lips; internal jaw stabilization is emerging
24 months Use of a sucking pattern for liquid intake; may hold edge
of cup with teeth; eventual development of internal jaw
stabilization without biting on edge of cup
Figure 1–5. Development of cup drinking skills. Source: Pediatric Dysphagia: Etiol-
ogies, Diagnosis, and Management (p. 75) by Willging, J. P., Miller, C. K., and Cohen,
A. P. Copyright © 2020 Plural Publishing, Inc. All rights reserved. Used with permission.
about the development of cup drinking skills.) Evie did not use a cup for
drinking and “has tended to lose liquid when she tries. She does not chew
while eating.” (See Figure 1–6 for a timeline of Evie’s medical history.)
Evie was taking famotidine 40 mg/5 mL (8 mg/mL) oral suspension.
This medication was prescribed to manage gastroesophageal reflux.
Evaluation
Lips: Appeared symmetrical. Pursing was evident. However,

anterior liquid loss was noted throughout the evaluation. No
drooling was observed.
Tongue: Appearance unremarkable. Tongue lateralization
was not observed when presented with soft solid textures.
Bolus organization, containment, and propulsion appeared
to be inconsistent, and there was decreased evidence of each
throughout the evaluation.
Jaw: Appeared symmetrical. Bite-through consistencies were not
presented to adequately evaluate emergence of rotary chew.
Hard palate/soft palate: Both hard and soft palate were
observed. Hard palate appeared high and arched, and soft palate
appeared normal.
Speech/language and communication: There was one
vocalization observed during the evaluation. Evie vocalized “uh,”
which appeared to be in response to her mom stating, “Uh-oh.”
Evie’s Case Study Timeline

• Born at 27 weeks’ gestation, maternal history positive for
drug use and hepatitis C
• 4-months in the NICU (Neonatal Intensive Care Unit)
• Discharged to foster care at 3 months old, adjusted age
• At the time of the 11-month evaluation, Evie lived with the
foster family. Weekly visitation with biological Mom
• Current diagnoses: gastroesophageal reflux, broncho-
pulmonary dysplasia, neonatal abstinence syndrome
Figure 1–6. Evie’s case study timeline.

Evie was placed in a Rifton chair. Foster mom fed her Stage 2 baby
food: mango and juice. Evie was prompted to accept bites from mom. She
did not readily open her mouth for each bite. She demonstrated limited
oral containment and propulsion but did not seem distressed in initiating a
swallow. Dissolvable puffs were presented one at a time. Evie was able to
contain the puffs but demonstrated limited tongue movement in propelling
them to the base of her tongue. When Evie was offered more than one puff,
she retained puffs in her cheeks. Foster mom reported similar behavior at
home and a need to pace Evie to avoid her mouth-stuffing behavior. Evie
was also observed to express approximately 1/2 to 1 oz of juice via a soft
spout sip cup. There were no overt signs of physiological distress as she
expressed the juice independently. (See Figure 1–7 for information on the
development of jaw skills for feeding and swallowing.)
The primary issues were poor oral containment and propulsion with
Stage 2 textures and lack of progression with more complex solids (e.g.,
Stage 3 baby foods, soft solids).
Diagnosis and Treatment Planning
Within the PDF definition, feeding and swallowing specialists should focus
on determining whether there are problems with oral skills, pharyngeal
skills, and/or esophageal skills. Often, this can be difficult to determine
during an initial evaluation. In Evie’s case, it was important to begin refer-
rals and work toward a differential diagnosis. At first, it was questionable
whether there were feeding skill issues for her. Interdisciplinary team
members were necessary. Her foster mother was also very diligent in com-
pleting a feeding log so that her skills could be more thoroughly assessed
outside of the outpatient therapy session.
What was an appropriate initial diagnosis for Evie? Consider the
International Classification of Disorders, 11th Revision (ICD-11) diag-
nostic codes. The potential codes were oral dysphagia, oral pharyngeal
dysphagia, pediatric feeding disorder–acute, and pediatric feeding dis-
order–chronic. (See Figure 1–8 for more information on differential
diagnosis in the feeding skill domain of pediatric feeding and swallowing
disorders.)
Who were the professionals currently involved in Evie’s care? (Evie
had a history of gastroesophageal reflux and was placed on a histamine-2
blocker by her pediatrician [Nguyen et al., 2022]). Did referrals need to
be made to further determine concerns regarding skill? What were poten-
tial obstacles to progression of skills in feeding and swallowing? (See
Figure 1–9 to see a list of team members for Evie.)
Feeding and swallowing therapy was recommended and a speech
and language evaluation within the next 3 to 6 months. The Pediatric
Age Range Lip, Tongue, and Jaw Motion in Response to Solids
5 to 6 months Phasic biting predominates
6 to 9 months Upper or lower lip may draw inward with presentation of food
Cheek and lip tense with side placement of food to hold in
place for chewing. Vertical jaw movements emerge during
attempts at mastication
Intermittent phasic biting occurs
Diagonal jaw movement occurs in response to food placed
on the surface of the gum
Lateral tongue movements begin to emerge
9 to 12 months Upper and lower lips pull in with presentation of food to the lip
Begin to see active lip motion in conjunction with jaw motion
Lips make contact in the center or the side as the jaw
moves up and down during chewing
Upper lip may move forward and downward during chewing
Vertical jaw movement occurs with intermittent diagonal jaw
motion
Tongue moves food from the center to the side of the mouth
during chewing
12 to 15 months Lips become active during chewing
Upper incisors or gums are used to clear food from the
lower lip
There is occasional loss of food or saliva while chewing
Diagonal rotary jaw movements increase
15 to 24 months Upper and lower lips are active during chewing
Ability to chew with the lips closed develops
Ability to control food intraorally without anterior loss when
lips are open emerges
Corner of lip and cheek draw inward to assist with control of
food placement
Jaw movements range between vertical, diagonal, and rotary
Circular rotary chewing occurs when transferring food
across the midline of the tongue from one side of the mouth
to the other
24 months and Basic set of skills is in place for chewing; movements are
beyond refined as the child continues to develop strength and
efficiency of chewing
Figure 1–7. Development of jaw skills. Source: Pediatric Dysphagia: Etiologies,

Diagnosis, and Management (p. 72) by Willging, J. P., Miller, C. K., and Cohen, A. P.
Copyright © 2020 Plural Publishing, Inc. All rights reserved. Used with permission.
7
International Classification of Disorders, 10th Revision (ICD-10)

Both feeding and swallowing diagnoses can be applied.
Feeding diagnoses
Pediatric feeding disorder — acute (present less than 3 months)
(ICD-10 63.31)
Pediatric feeding disorder — chronic (present for 3 months or more)
(ICD-10 63.32)
Swallowing diagnoses
Dysphagia, oral phase (ICD-10 13.11)
Dysphagia, oropharyngeal phase (ICD-10 13.12)
Dysphagia, pharyngeal phase (ICD-10 13.13)
Dysphagia pharyngoesophageal phase (ICD-10 13.14)
Figure 1–8. Differential diagnosis in the feeding skill domain for pediatric
feeding and swallowing disorders. Adapted from World Health Organization.
(2022, August 31). International Classification of Diseases (ICD). https://
www.who.int/standards/classifications/classification-of-diseases
Biological parent Occupational therapist
Early interventionist Pediatrician
Foster parent Registered dietician
Gastroenterologist Social worker
Figure 1–9. Team members for Evie.
Eating Assessment Tool (Pedi EAT), a parent-report instrument developed

to assess symptoms of feeding problems in children aged 6 months to
7 years (Thoyre et al., 2018), provided information to guide treatment. Ini-
tially, there were concerns about lack of food exposure. Evie’s foster mom
expressed concern about offering Stage 3 and soft solids that Evie was not
ready to handle. Another concern was whether there were physiological
reasons for food refusal behaviors. There were no signs and symptoms
that would suggest pharyngeal difficulty (e.g., frequent upper respiratory
infections). Work on feeding skills was initiated (Morris et al., 2000) and
a referral to gastroenterology was made. (See Figure 1–10 for a listing of
assessment protocols available for pediatric feeding and swallowing.)
Assessment Protocols Comments
About Your Child’s Eating • Measure of child-parent feeding relationships for

(AYCE) children ages 8 to 16 years with chronic illness
American Speech- • Variety of consensus-based templates for infant,

Language-Hearing toddler, and adolescent feeding assessment
Association Sample
Templates for Evaluation
http://www.asha.org
Behavioral Pediatric • 35-item scale

Feeding Assessment • Identification of feeding issues in children with a range
Scale (BPFAS) of conditions
• Includes caregiver perceptions
Bristol Tongue Assessment • Assessment of tongue appearance and function in

Tool infants with tongue tie
• Rates severity of tongue tie
Children’s Eating Behavior • Assessment of eating and mealtime problems in

Inventory (CEBI) children ages 2 to 12 years
• Parent report form
Dysphagia Disorder • Survey designed to identify and describe swallowing

Survey and feeding disorders in children and adults with
developmental disability
• Tested for reliability and validity
Dysphagia Management • Five-level scale for rating severity of dysphagia based

Staging Scale (DMSS) on management needs and health-related outcomes
• Requires certification for use
Early Feeding Skills (EFS) • 36-item checklist for assessing infant oral feeding
readiness, oral feeding skill, and oral feeding recovery
Functional Oral Intake • Rates degree of oral intake on a 7-point ordinal scale,
Scale (FOIS) beginning with tube dependency and ending with total
oral intake with no restriction
LATCH • Breastfeeding charting system that provides a

systematic method for gathering information about
individual breastfeeding sessions
Marshalla Oral • Assessment of oral movements, oral-tactile sensitivity,

Sensorimotor Test oral and facial tone, resonance, and respiration and
(MOST)™ phonation skills
• Criterion referenced scores for ages 4 years to 7 years,
11 months
Mealtime Behavior • 33-item questionnaire in which parents are asked to

Questionnaire rate mealtime or feeding behaviors over the past week
Figure 1–10. Examples of assessment protocols. Source: Pediatric Dysphagia:

Etiologies, Diagnosis, and Management (p. 315) by Willging, J. P., Miller, C. K., and
Cohen, A. P. Copyright © 2020 Plural Publishing, Inc. All rights reserved. Used with
permission. continues
9
Assessment Protocols Comments
Montreal Children’s • 14-item parent report tool designed to identify feeding

Hospital Feeding Scale problems in children 6 months to 6 years of age
Neonatal Oral-Motor • Observation of normal, dysfunctional, and

Assessment Scale disorganized tongue and jaw movements in infants up
(NOMAS)® to 8 weeks of age
• Requires specific training for administration
Oral Motor Feeding Rating • Screens and categorizes oral motor movements
Scale • Age 1 to adults
Parent Mealtime Action • Measure of child feeding practices

Scale (PMAS) • Identifies specific parent practices included in
“permissive feeding”
Pediatric Assessment • Parent-report measure for progress in development of

Scale for Severe Feeding oral feeding skills in children who require prolonged
Problems (PASSFP) tube feeding
Premature Oral Feeding • Objective criteria to assess preterm infant readiness to

Readiness Assessment breastfeed
Scale (POFRAS)
Preterm Infant • 10-item scale administered to assess feeding

Breastfeeding Behavior readiness
Scale (PIBBS) • Rates gestational age, color, activity, state, cues, and
tone
Pediatric Eating • Parent-report measure of problematic feeding

Assessment Tool behaviors
(Pedi-EAT) • Content validated
Schedule for Oral Motor • Assessment of oral motor skills in infants and toddlers
Assessment (SOMA) between 8 months and 24 months of age
• Tested for reliability and validity
Screening Tool of Feeding • Measures a range of feeding problems in children

Problems (STEP) applied (both normal and with special needs) between ages 24
to Children (STEP-CHILD) months and 18 years
Systematic Assessment • Observations of latch, compression, and audible

of the Infant at the Breast swallowing during breastfeeding in full-term infants
(SAIB)
Source: Adapted from (1) Heckathorn, D. E., Speyer, R., Taylor, J., & Cordier, R. (2016) Systematic
review: Non-instrumental swallowing and feeding assessment. Dysphagia, 31, 1–23. (2) Pados, B.,
Park, J., Estrem, H., & Awotwi, A. (2016). Assessment tools for evaluation of oral feeding in infants
less than 6 months old. Advances in Neonatal Care, 16, 143–150.
Figure 1–10. continued

Case Study Intervention
(See Figure 1–11 for areas of concern for Evie identified through the
evaluation process.) The following goals were addressed: (a) skills in oral
containment and propulsion with more complex textures, (b) ability to
identify and label oral structures and functions (e.g., lips, tongue, teeth),
(c) thin liquid expression through various modalities, and (d) emergence
of typical meal consumption.
Treatment approaches utilized: sequential oral sensory (SOS), food
chaining, tools (e.g., seating system and specialized utensils), modeling,
and shaping.
As therapy was initiated, the caregiver and clinician were concerned
about Evie’s heavy reliance on formula to meet nutritional needs. Evie’s
lack of sustained attention during mealtimes and challenges in getting her
to remain seated were also obstacles. Grazing could easily be a pattern of
feeding for Evie given her resistance to remaining seated for more than a
few minutes.
More overt food refusal behaviors were also an immediate concern.
Spitting out and turning her head were observed at different times of day.
Intermittent reflux and emesis were also reported.
Consider important questions to ask as these behaviors and the emesis
have emerged. The following questions could be posed: (a) Can you tell
me about an incident when Evie threw up during the past week? (b) Do
Oral Evie’s
Preparatory
Phase
Potential Areas
of Concern
Oral
Transit
Phase
Pharyngeal
Phase
Esophageal
Phase
Figure 1–11. Evie’s potential areas of concern.

you remember the food that she ate that day? (c) Tell me about her food
refusal. How does her food refusal this week compare to the previous week?
Opposition to remaining seated can inhibit progression of skills in
many ways. Mealtimes can be reduced. Sensory exposure to less familiar
foods can be lost. Caregivers and family members are unable to model
mealtime behaviors. Ultimately, encouraging a child to comply through
timers and a more restrictive seating system may be beneficial. However,
reasons for elopement from a seated mealtime should be considered. Was
there any pain or discomfort causing Evie’s opposition to remaining seated
during mealtimes?
It can be helpful to guide parents through the referral process — for
example, letting Evie’s parent know that reporting the emesis and food
refusal behaviors might help her get the testing needed to rule out pain
or discomfort related to oral intake. The gastroenterology referral could
be followed up with a phone call. Opening that line of communication by
stating exactly what the concerns were leading to the referral could lead
to the most efficient medical care. We wanted to determine if there was
discomfort caused by gastric motility issues. Given Evie’s continued use of
acid-reducing medication for gastroesophageal reflux and drug exposure,
there was enough information to suggest a gastrointestinal obstacle to skill
progression. Evie’s gastroenterologist performed an esophagogastroduo-
denoscopy (EGD). Results of this procedure suggested some irritation at
the level of the lower esophageal sphincter.
Evie’s Feeding Journal
The following detailed feeding journal was completed by Evie’s foster

mother and provided a window into one of her three feeding environ-
ments. Evie also spent time with her biological mother during the week
and was in full-time daycare. This wasn’t the entire story, but it was a
wonderful guide.
Changes in feeding and swallowing skills occur so quickly and causal
factors vary (e.g., illness, schedule or caregiver differences). This journal
provided important insight into Evie’s sequence of feeding, a stronger
understanding of food refusal behaviors, and guided how to best intervene
during subsequent therapy sessions.
Week 1: Ate a few bites of the ravioli but definitely not as

excited about it as she was on at feeding therapy. Choked on the
fourth and fifth bites and then she took the bites off the spoon,
moved them around in her mouth, and then spit all of them back
out. Same with the pepperoni pieces and bread pieces. “Chewed”
on them but would not actually swallow them, just spit them
back out on her bib. Made some of the oatmeal and barley apple
and cinnamon toddler meal and she was excited, leaning forward
for bites, opening mouth wide and kicking her legs in excitement
just like she did the raviolis at feeding therapy.
Week 2: 6 a.m.: 4-ounce bottle. 9 a.m.: No formula. Ate one jar
of mango baby food. Eagerly ate the first 3/4, started getting
fussy at the last quarter of a jar, started spray spitting the last two
bites swatting with the last four or five bites. 12 p.m.: 4 ounces
of formula. Did not nap very well at all. 3 p.m.: Handful of star
puffs and another jar of mango baby food. Once again, eagerly
ate the first 3/4, started getting fussy at the last quarter. Started
spitting at the last two or three bites. About 3 ounces of mixed
fruit flavor Revitalyte in sippy cup after snack. Barbecue chicken
and potatoes for dinner at 6 p.m. She ate a few bites of chicken,
sometimes spitting it out when I put it back in. She would
usually chew it up a little bit more and swallow it. After about 8
to 10 bites, she would chew it, and spit it out. She would then
refuse to swallow any of it. I gave her some potatoes, sometimes
with a little bit of barbecue sauce on them and she ate those
very well. Sometimes I slipped a small amount of chicken in with
it, and she would eat it and swallow it. Eventually she just started
spitting the potatoes back out. Gave her a small amount of juice
between bites, trying to help her get some of the food down.
Sometimes it helped, sometimes it didn’t. 4 ounces of formula at
6:30 p.m. before bed.
Next day: 7 a.m.: 4-ounce bottle with vitamins and medicine.
8:45 a.m.: tried a couple of bites of maple and brown sugar
instant oatmeal but wouldn’t eat it. I made a small bowl of rice
cereal mixed with formula. She ate all of it and about 2 ounces
of formula before naptime. I had difficulty getting her to go to
sleep. Wi-Fi was not working so there was no music, just lullaby
music from her vibrating puppy dog. She fell asleep for about
20 minutes, and she’s acted sleepy since she woke up at 7 a.m.
3 p.m.: Snack was blueberries, apple baby food, and star puffs.
She had star puffs around 5:30 p.m. and some apple cider while
at the fall festival. We came back to the house to eat dinner. She
would not eat potatoes this time. Maybe they were too hot or not
soft enough, although most of them were soft. She ate a bowl
of rice cereal with baby formula mixed in and a few more puffs
with some Pedialyte. 4 ounces of formula before bed.
Next day: 6 a.m.: 4 ounces with vitamins and meds. Tried
some rice cereal mixed with formula at the 9 a.m. feeding but
she only took a few bites. She gagged once, and then started
spitting it back out, “spraying” it back out. She stopped taking it
altogether. I gave her 3 ounces of formula at 9 a.m. 12 p.m.:

4-ounce bottle. 3 p.m.: Most of a pouch of puree squash/chai,
and apples. 5:45 p.m.: She had potatoes. She ate about 3 to 4
small potatoes and about 3 to 4 bites of puree turkey and then
started spray spitting it out at me again (both). I gave her some
star puffs between a few bites of potato, and she would take a
few more bites. But then, she started spitting it out again. I gave
her a few more stars and she put them in her mouth but then
spit most out.
Evie progressed in feeding and swallowing skills. She improved in

oral propulsion and containment. She was eating a variety of tastes and
textures without evidence of food refusal for consecutive weeks. She
improved in thin liquid expression skills through a variety of modali-
ties. Three months postintervention, Evie was no longer using a bottle.
Problems with elopement and grazing were also shaped. Gastrointes-
tinal follow-up appointments were necessary with less frequency. The
frequency of feeding and swallowing therapy decreased, and eventually
Evie was discharged.
Discussion
This case study provides an example of how caregiver involvement can

improve treatment outcomes. Evie’s biological and foster mom both
attended treatment sessions. A weekly feeding log was completed by her
foster parent, giving us an increased window into the mealtime routines
and an increased understanding of food refusal behaviors. Her caregivers
asked questions, collaborated in goal creation, and complied with provider
recommendations. Increased exposure to a variety and tastes and textures
was important.
There were challenges in team communication to gain adequate
information about Evie’s skill progression in both environments. The
biological parent had a history of drug use throughout the pregnancy,
which most likely affected her ability to integrate and function as a valued
member of the team. Different feeding practices in each household may
have been related to differing socioeconomic status or eating practices.
Careful navigation was important to provide the best care. See Figure 1–12
for information on sharpening clinical skills in cultural humility to begin
examining how critical self-reflection of one’s biases and privilege can
facilitate better treatment team building.
A few key areas that began to emerge were limited variability in food
presentation (always presenting Stage 2 mangoes) and that food refusal
behaviors may be Evie’s communication (spitting out food as a sign of
fullness or physiological discomfort). Habitual presentation of the same
• Place value on the client as the expert on their own culture.

• Be aware of the client’s cultural background in the moment with critical self-
reflection of one’s biases and privilege.
privilege
• See yourself as an active collaborator with the client during both the
assessment and treatment processes when figuring out how to be aware of
their cultural needs.
• Build a genuine relationship in therapy with the client that is based on mutual
goals, tasks, and a collaborative process.
From My Perspective/Opinion: Moving Forward as a Profession in a Time of
Uncertainty
Cultural competence and cultural humility are the gold standard in
communication sciences and disorders.
By Kyomi Gregory, August 4, 2020
Figure 1–12. Sharpening clinical skills in cultural humility. Adapted from Gregory,
K. (2020, August 4). From My Perspective/Opinion: Moving Forward as a Profes-
sion in a Time of Uncertainty. ASHAWIRE. https://leader.pubs.asha.org/do/10.1044/
leader.FMP.25082020.8/full/
tastes and textures had occurred when a lack of textural progression

was observed. Instrumental testing and observation of structure and func-
tion helped provide evidence that Evie was capable of handling textures.
Communicating these skills to the caregiver helped in their comfort with
transition to textures beyond puree.
A gastroenterologist referral was important. Instrumental evaluation
of structures provided information that structure and function were areas
of concern that required medical management (e.g., increased dosage of
gastroesophageal medication).
Evie’s diagnosis of pediatric feeding disorder that was chronic in
nature was accurate. Initiating a few different processes simultaneously
proved a successful approach for Evie. The success of her case was due
to an interdisciplinary approach, caregiver involvement in the treatment
process, and a facilitated progression of skills.
While Evie’s case does represent a period of disordered feeding and
swallowing skills, this is an example of progression through short-term
intervention. The intervention led to parental/caregiver education and
empowerment. Evie was able to transition to an age-appropriate diet as
team-based problem solving occurred.
Evie’s case study provides an example of a complex medical history.
She was the product of a premature pregnancy, low birthweight, and
exposure throughout pregnancy to a variety of drugs. It is difficult to deter-
mine the long-term effects of neonatal abstinence syndrome and how they
play into this case. Digestive motility did appear to be a factor in feeding
skill progression. As Evie develops, there may be a need to pursue food
sensitivity and allergy testing.
INTERVIEW WITH DR. KATLYN

MCGRATTAN, PhD, MA, CCC-SLP
Dr. Katlyn McGrattan talks about the importance of understanding normal

infant feeding behavior. She has begun researching normal infant feeding
behavior through various projects and provides a framework for a pro-
vider when determining normal versus disordered feeding and swallowing
skills. Dr. McGrattan also discusses the practical way of integrating reason-
ing and clinical judgment with current research.
Jennifer Wilson ( J): I’m really excited about our profession’s emerg-
ing research agenda in normal feeding and swallowing. I thought it
might be nice just to do an overview of some things that we need
to learn about normal feeding and swallowing. I know that’s a very
open-ended question.
Dr. Katlyn McGrattan (K): Everything. I think that we need to know
so much more starting from just looking at sucking physiology
and moving on to pharyngeal physiology, the interaction between
the two, and how those interchange with respiration. That’s a very
vague answer. Generally, we have the most data on what’s normal
for sucking physiology because it’s the least invasive to measure. It’s
relatively easier to measure than the other components. Even looking
at that, it’s striking how little we have. The data that we have mostly
looked at sucking physiology with bottle-fed babies, because that’s
easier to measure. So that’s a limitation. We don’t really know much
about differences in sucking physiology between bottle and breast
with good data behind it. Most of the studies that people have done,
looking at bottle feeding, don’t control the nipple flow rate and other
variables. We know from research that we have the strong potential to
influence sucking physiology, but we don’t have norms or anything
like that. So, I think from a sucking physiology standpoint, we know
the basics, but we really need to get more correlates of how that is
influenced by different flow rates on a clinical level. Then moving
on from a swallowing level, we know very little about swallowing
physiology in normals (normally developing children). That, to me,
is a huge focus. That is where I see the void inhibiting clinical care
the most. We’re doing swallow studies and we’re making conclusions
about deficits, but we really don’t know what normal is. Until we
have a better understanding of normal, whether we get that from a
swallow study or some other type of instrumental assessment, then
I think we’re always going to be held back in understanding what
we’re aiming for. So, those would be the main things from a big
picture perspective.
J: There’s also the different types of formula and versus breast milk
variable.
K: Yeah, there’s so many variables. We’re doing a study right now
measuring sucking physiology in babies in their house. People know
that state changes sucking to an extent, and we all have experienced
clinically that the feeder might change feeding. For example, a baby
might come into my office, and I’ll look at them. As soon as they
see me watching them, they start feeding weird because they’re dis-
tracted. There are all these things that we think make a difference,
but we don’t really know exactly what influence that is yet. We may
be artificially setting our kids up to look better or worse than they
typically do. So, I think really getting at that more is important and
relatively easy from a research standpoint, getting healthy babies for
research is much easier. They are more abundant than getting the
sick ones in the hospital.
J: How do you measure state changes in the normally developing
babies?
K: Yeah, so I know they have scales that can be used. I’ve used some
of those scales in the past, which is good, but there are so many
variables that sometimes it’s overwhelming. In the hospital setting,
because like you said, there are so many comorbidities and different
variables you can’t control for. Some clean studies are needed to
weed out some of those things. And even just looking at variability. In
some of the research we’ve been doing in looking at healthies, we are
seeing that kids are so variable. We always appreciate that medically
fragile kids are variable, especially our preemies, but I don’t know
that I fully appreciated, until doing the study, how variable healthy
term babies are in how they feed. Some of our studies look at how
often they cough and some days they cough a ton and others, they
don’t. This is observed when they’re fed from the same bottle. It
doesn’t seem like it makes sense that they would change that much,
but sometimes it can be messy data, so we’ve got to sort through that,
so we know what to make of it clinically.
J: How has your work with disordered feeding and swallowing driven
your research on normal feeding and swallowing skills?
K: Looking at normals has always been kind of a step one goal for
me. To me it seems like it makes most sense to figure out what we are
trying to get at. What are we aiming for? And then work backwards,
to see how some of these babies have functional impairments. What
are they doing that is making it so that they can’t feed well relative
to their healthy peers?
Whether I’m seeing patients clinically or in a research study, it
always comes back to what the healthies are doing, because we need
the comparison. The other topic is that healthy babies don’t feed per-
fectly. Sometimes, we look for perfection. I think, the more we know
about the imperfections in a healthy, functional, term baby’s feeding,
it can shed light on what type of imperfections in an impaired baby
are OK versus not OK. It’s a circle, but those healthy full-term babies
are the foundation.
J: Many parents are constantly questioning that, aren’t they?
K: I wonder how much of that is Internet and different in our culture
currently compared to maybe like 20 years ago or 30 years ago. We
are much more into expecting perfect everything. A lot of millennials
are starting to have babies, right? And that is a different trait. I think
parent reports are always important to any interview and taking that
is a huge part of what’s going on as far as functional problems. It
always makes me wonder, how much should I put on that? Some-
times, parents will describe things to me that don’t sound that bad,
like it doesn’t sound that abnormal or concerning. They are coming in
concerned about it so it’s hard to weed out. Are they not expressing to
me how bad it is in a way that I can quantify? Are they kind of getting
more upset about something that is normal? You know, I don’t know.
It’s kind of like the reflux thing, like all babies have reflux. People
keep putting their babies on medicine to make it stop, but that’s a
normal part of infancy.
J: That’s another tough one, reflux management. You’ve made a good
point in appreciating when you’re serving this population that so
much of the work is with parents and caregivers. Validating what
they’re saying, appreciating what you’re hearing from them is so
important. I try to appreciate that it’s the most challenging thing at
that moment. We may see it as more of a molehill maybe, and it’s to
them, it’s a mountain.
K: At the end of the day, regardless of whether what their babies are
doing is normal, it’s causing a lot of stress. I think that’s a key thing.
The first thing is realizing this parent is feeling a lot of stress based on
how this baby is feeding. Now let’s determine if the baby truly does
have a problem or they don’t. That will be like the next ideal thing to
figure out, how to move forward. If what you find and what you’re
seeing is that, well, this seems consistent with normal neuromotor
immaturity and this isn’t something that truly should be classified
as an impairment or warrants an intervention that would potentially
cause more harm than good, right? Like thickening or something
then? That doesn’t mean that you just say, “OK, no, they’re fine. See
you later.” I think, in part, helping the parents to understand what is
normal and what we would expect is important because that gives
them peace of mind at least that, “OK, yes, this is not an ideal situa-
tion, but that is expected. It’s not like there’s anything crazy wrong
with your kid based on what we’re seeing if that is the case.” And
then, continuing to support them. And I think that again comes back
to the variability issue. Maybe that parent’s complaint and concern
that they come in with, you don’t see it in that clinical evaluation.
Well, babies are so variable, so I don’t think you should stop at that
point and send them out the door. Have them come up for a follow-
up or two to see if you can better understand what their concern
is or see if they can do a video or something like that to help you
understand what’s happening when their babies are out of the office
with you.
J: There can be so much inconsistency in performance. And it can be
difficult to fully appreciate what the challenge is right away, and so I
think like you’re saying, follow up in parent education. What are some
suggestions that you might have for students and young professionals
who want to gain skills in pediatric dysphagia?
K: My biggest recommendation I have for my students is to “cali-
brate yourself to normal.” Many young clinicians going into the field
haven’t had kids of their own. They probably haven’t had that many
young infants, or if they have, they haven’t tried to evaluate different
parameters that we evaluate in a clinical exam.
J: What are some good ways to “calibrate to normal?”
K: Finding a daycare center and seeing if you can get involved there.
A volunteer internship that allows you to feed the babies when they
are due to eat. Find a Facebook group. If you have families, there’s
often new moms, families, and there you explain what you’re doing.
I’ve been amazed at how many different opportunities I get through
Facebook from research. Families are usually very eager if it’s not
invasive. Most parents are happy for you to feed their babies so they
can take a shower. But another way to gain experience is if you go

to any of the pediatric wards in your hospital that are seeing babies
for things other than feeding problems. Maybe they had ear tubes put
in or you know X, Y, or Z. Trying to set something up there where
you can help the nurses feed the babies for them so that you can
better evaluate how do healthy babies without functional problems
feed? I think the other general recommendation is to keep in mind
that just because you have a “hammer” doesn’t mean “everything is
a nail” phenomenon. We become biased into looking for problems
and we’re seeing kids with problems. For example, we get a referral,
then we’re immediately like, “Oh yes, this is a problem.” I think that’s
very common. You’re consulting because there’s a problem. You are
looking for deficits versus knowing that there is some normal variabil-
ity, imperfections that we’re starting to uncover. Don’t go in expecting
a baby to feed normally. That’s easier said than done because we don’t
have great data on what is normal yet. Hopefully we’ll have that for
you soon, but I think that’s just important to keep in mind. Looking
at functional outcomes, not just physiology. I love physiology. I love
measuring things. That is what I love to think about. But, at the end
of the day, what matters most is function and so if you have slight
impairments in physiology, but you still have function, then that’s
fine, right? I talk to my students about looking first at what are the
functional outcomes? For a baby it’s, “Can they meet nutritional needs
with cardio, pulmonary stability? Can they take full nutrition orally
without having any bradys, apnea, desats, respiratory infections.”
And then likewise, without stress from the baby or the parent. (See
Figure 1–13 for more information about these terms related to an
infant’s stability for oral feeding.) Those are the primary functional
outcomes. Look at those in an infant. Is one of those impaired, if any,
and how’s physiology related to that? That’s how I weed out what is
important and what’s not. That’s how I determine how conservative
I should be in treatment.
Bradycardia — slower than expected heart rate

Desaturation — low blood oxygen concentration
Apnea — cessation of breathing for more than 20 seconds or a
shorter respiratory pause associated with oxygen desaturation
and/or bradycardia in infants who are younger than 37 weeks’
postmenstrual age (PMA) at birth
Figure 1–13. Some terms related to infant stability to feed orally.

J: Any other thoughts about what you’re seeing therapeutically in pedi-

atric dysphagia? What’s going well in terms of treatment approaches?
K: We’re getting more research in the area, so I think that’s encour-
aging. People are looking at the mechanism and bringing more
answers, which is good. It seems like most clinicians understand that
these feeding disorders are multifaceted. You need an interdisciplin-
ary approach to them. Along those lines, it is important to realize
the scope of what your expertise is and engage those other team
members. Don’t necessarily do so in a black and white way. In my
clinical practice, most feeding problems are very much in a gray
area. There’s very few that are black and white. I very rarely give a
black and white answer to families or providers. For example, I’ll get
a swallow study and I might say the conservative option based on
what we saw in this exam is to do A and then a more liberal approach
would be to do option B. So, for example, if you have a baby that had
trace aspiration of thin liquids, but they haven’t had any respiratory
problems, I would, in that case, 100% divert to the medical team that
knows that baby far better than I do from a systemic health stand-
point, and I’ll say, “Well, this baby had trace aspiration, but overall,
their physiology looks good.” Given that they haven’t been having any
respiratory problems and they’re healthy, they’re having breast milk,
then one could say, “Let’s continue doing breast milk, thin liquids.
We will slow the flowrate a little bit.” Hopefully, they reduce how
frequently that happens and then we will monitor them very closely
and make sure that they are maintaining a good standing. If we start
to see that they are having any type of problem, respiratory wise or
with discomfort, then we can look at a more conservative approach,
which would be thickening. We may have to take them off breast milk
XYZ. Ideally, I don’t really take babies off breast milk if we feel like
they can be safe at all on the way that they’re feeding. We know the
benefits of human milk are so great. Likewise, I would potentially also
say, “That being said, if you’re concerned that this baby can’t tolerate
any aspiration (maybe it was a hypoplastic status post repair Stage 1
palliation), if you feel like they can’t tolerate any aspiration, then the
best method would be thickening liquid.” I will typically provide a
couple of options. If it’s not a straightforward case, which most aren’t,
then I go to the team, and I’ll talk to them about it and see where
they stand on it. They typically appreciate that, and I think it makes
sense because again, I don’t know how much aspiration that baby
can take, if any. I think it’s good to always get their feedback instead
of treating it like this is the only potential route to go.
J: I love the way you present different options.
K: I always tell them there’s two paths and then I will feel like some
are so overwhelmed by the problem that they want to be told what
to do, they want to rely on your expertise. What do you recommend?
I completely appreciate that, but I think it’s important for them to
know that it is not black and white. This seems like the best option
right now, but we can reevaluate it and see. Other families want to
be really engaged and they know their child well. They may have
a background in a medical field, or, at this point, their child has
had so many procedures that they essentially have a background
in the medical field. I think it’s just good to give options and not
treat it like this is the only route. Really, I don’t think that’s typically
the case.
J: Cases in pediatric dysphagia are difficult to research given their
multifactorial nature. How can we put our best foot forward consider-
ing the evidence is not always available to support our treatment?
K: We don’t have enough research to know how much aspiration
is too much. How much of a stress cue is too much? We’re doing
this normal analysis on healthy, functional babies without reports of
feeding problems and in looking at how they feed, they show stress
cues. A lot of them show stress cues throughout the feed on occasion,
like it’s not the entire feed. So, I think the bottom line is just acknowl-
edging that we don’t know it all, and that’s OK. No profession knows
it all. But I doubt that any profession feels like they’ve completely
figured it out. There probably will always be questions that we don’t
have answered yet. But I think while we’re working to gather that,
just accepting that we don’t know it all. I tell patients and providers
that, “This is a new science, and that we don’t have a ton of data on.”
We can apply what we do understand, and it can guide us exactly
on the best way to move forward given this situation. I think people
appreciate that honesty as you move forward. Everyone is like, “Don’t
hesitate to say that you don’t know, and the profession doesn’t know.”
I think generally people can appreciate that you’re honest and you
bring it from an evidence-based perspective. There’s no evidence
here yet, but based on theory, that’s what I typically say. There’s no
evidence for this. There’s no research I’ve seen in this area but based
on theory. Therefore, I’m moving forward that way, and so, giving a
rationale for that. But that kind of piggybacks into my second reason,
my second thing is: We have so little hard data and research to guide
in many areas of our practice that I think in order to perform best
practice and best evidence-based practice, you as a clinician need
to make sure you have a strong foundation in physiology and the
evidence that surrounds that. If you understand physiology and how

different variables affect physiology, then I think that you can be your
own scientist from a clinical perspective. For example, If I’m doing a
study, my hypothesis is this and the reason for that is that previous
research has shown X, Y, and Z and therefore we would anticipate
that this would influence it this way. Clinically, I do the same thing. I’ll
say, we don’t have research to indicate what we should do here, but
we know based on how physiology works that if we move the baby
into this position, it might influence their vital capacity and because
that position has better vital capacity. No one’s ever looked at it while
feeding. I think if you have a strong foundation of physiology and
how different potential treatments that you have applied you know
relate to that, then you have at least the theory for why you would
do something in the absence of science, I think that’s a good place
to be. That’s all you can really ask for.
J: Let’s talk about some other obstacles to treatment. You’ve got all
those other professionals at your fingertips in a hospital setting. How
does that look different when you’re in more of a rural setting? Any
thoughts about that?
K: Yeah, I think it’s hard. There’s a reason I don’t practice in that
setting. That’s hard, you know. I admire everyone in that. I think I feel
for people in that area because your hands are kind of tied to some
extent. You don’t have access to a lot of times, the equipment as much
as would be ideal, right? I’ve worked in both rural and urban settings.
I would not say rural, but I’ve worked in more outpatient clinics not
associated with a hospital setting before. I can appreciate those pain
points where the medical team is kind of like, “Well, this is what
you’re doing.” But then, I’m like, “But I’m seeing this patient weekly
and you’re not. This is what I’m seeing.” So, my biggest recommenda-
tion from being on both sides is if you can pair up with a clinician
at a medical setting, that is so valuable for both of you. We would
be constantly discharging patients from the hospital and to find a
well-trained clinician in more of an outpatient setting sometimes felt
like an act of God for these medically complex kids. We have a list
of certain ones we refer children to for outpatient services. We want
them to go to this person because we know that you will take care
of them and we would communicate with them well because we had
that relationship with them, and we knew they were well trained so
we could speak the same language. If you’re feeling like you are “on a
little island,” what I would recommend is just seeing if you can reach
out to some of those clinicians at the hospitals. Maybe set up a time
to get coffee and just talk about what their needs are from discharging
and getting continuity of care from the other side of things. See how
you can collaborate more closely so that you can get more of that
team science and communicate for optimally better care.
J: That’s wonderful and it really sets up a mentoring kind of relation-
ship in some ways too potentially. There may be age and experience
difference or just maybe some different skills that the acute care
specialist is bringing to the table versus that outpatient specialist,
and vice versa.
K: Typically, levels of care are so completely different, and I think
that’s so great to share those varied perspectives. I had an outpatient
clinician that was seeing that kid and the baby was coming in for
swallow study. I knew that I would get an email from them saying,
“This is what we’ve been doing. This is what we specifically have
concerns about.” That was awesome because I can do a swallow
study, but if I’m seeing or hearing what’s happening clinically, it is
better. If I can cater to what’s happening for that patient and I can
easily send you the results that way, then I don’t have to try to hunt
down the child’s therapist and send it through the parent. It’s better
for families, it’s better for everyone.
J: Let’s talk about the research that you’re doing more specifically.
You touched on it just a little bit, but can you talk about the work
that you’re doing to gain more information about normal oral and
pharyngeal processes?
K: We’re doing two big studies right now. The first one is a home
monitoring study where we’re trying to better understand how many
times healthy term babies cough when they feed. Small outcome.
Pretty simple outcome. We’re looking at other things, including how
much they eat and drink, how frequently they eat and drink, how
long it takes them. Things like that. We’re trying to get a better under-
standing of whether signs of aspiration are normal on occasion. Does
this change throughout the course of development? We’re looking at
this over the first 6 months of life. And then, are there differences in
how frequently babies show signs of aspiration in bottle-fed babies
versus breastfed feeds? We are hopefully going to be consenting our
last participant probably tomorrow or Friday. She was in labor earlier
this week and was texting me from the delivery room. I feel like I’ve
been in the delivery room with lots of people from the study. We
will have 65 individuals in the study, and they’ve been longitudinally
studied for 6 months. We have all that information on them, and the
Another random document with
no related content on Scribd:
trade for ten days. As many as 20,000 horses are brought there for
sale from Beder, which is 20 kors distant, and besides every
description of goods; and that fair is the best throughout the land of
Hindostan. Everything is sold or bought in memory of Shikhbaludin,
whose fête falls on the Russian festival of the Protection of the Holy
Virgin (1st October).
In that Aland (Aladinand?) there is a bird, gukuk, that flies at night
and cries gukuk, and any roof it lights upon, there the man will die;
and whoever attempts to kill it will see fire flashing from its beak.
Wild cats rove at night and catch fowls; they live in the hills and
among stones. As to monkeys, they live in the woods and have their
monkey knyaz, who is attended by a host of armed followers. When
any of them is caught they complain to their knyaz, and an army is
sent after the missing; and when they come to a town they pull down
the houses and beat the people; and their armies, it is said, are
many. They speak their own tongues and bring forth a great many
children; and when a child is unlike its father or its mother, it is
thrown out on the highroad. Thus they are often caught by the
Hindoos, who teach them every sort of handicraft, or sell them at
night, that they might not find their way home, or teach them
dancing.—From India in the Fifteenth Century, in the Hakluyt Society
Publications, London, 1857.
FOOTNOTES:
[113] A thousand-man of the Russian army.

[114] Probably a mistake for Kaffa in the Crimea.
Apocryphal Legends about King Solomon. (XV.
century.)
Among the many apocryphal stories of the Old Testament
that were current in Russia the largest number centre about
King Solomon. They are mostly derived from Byzantine
sources which, in their turn, are often based on Jewish
apocryphal accounts; thus the Story of Kitovrás (evidently
transformed from Centaurus) is also given in the Talmud.
Kitovrás is mentioned in Russian literature in the fourteenth
century, but the following passage is from a manuscript of the
fifteenth.
THE STORY OF KITOVRÁS
Then came Solomon’s turn to learn about Kitovrás. He found out

that his habitation was in a distant wilderness. Solomon, in his
wisdom, prepared a steel rope and a steel hoop, and on this he
wrote an incantation in the name of God. And he sent his best boyár
with his men, and ordered them to take with them wine and mead,
and the fleece of sheep. And they came to the appointed place, and
behold, there were three wells, but he was not there. By the
instruction of Solomon, they emptied the three wells, and closed the
springs with the fleeces of the sheep, and filled two of the wells with
wine, and the third one with mead, but they themselves hid
themselves nearby, for they knew that he would come to the wells to
drink water. And he came, for he was very thirsty, and he lay down to
drink, but seeing the wine, he said: “Nobody becomes wise from
drinking wine.” But as he was very thirsty, he said again: “You are the
wine that gladdens the hearts of men,” and he emptied all three
wells, and lay himself down to sleep. The wine heated him up, and
he fell into a deep sleep. Then the boyár approached him, put the
hoop upon his neck, and tied the steel rope to him. When Kitovrás
awoke, he wanted to tear himself loose. But Solomon’s boyár said to
him: “The name of the Lord is upon you with a prohibition”; and he,
seeing the name of the Lord upon him, went meekly along.
His habit was not to go by the crooked road, but by the straight
road; and when he arrived in Jerusalem, they levelled the road for
him, and palaces were destroyed, for he would not go by the
crooked road. They came to the house of a widow. She wept loud,
and she begged Kitovrás with the following words: “I am a poor
widow.” He turned around the corner, without leaving the street, and
he broke a rib, and said: “A gentle word breaks bones, but a harsh
word rouses anger.” As he was led through the market-place, he
heard a man say: “Is there not a shoe that will wear seven years?”
and Kitovrás laughed out loud. And he saw another man who was
telling fortunes, and he laughed; and he saw a wedding ceremony,
and he wept....
Solomon asked Kitovrás: “Wherefore did you laugh at the man that
asked for a shoe that would last seven years?” And Kitovrás
answered: “As I looked at him, I saw that he would not live seven
days.” And Solomon said: “Wherefore did you laugh at the fortune-
teller?” And Kitovrás said: “He was telling people hidden things, and
he did not himself know that a gold treasure was right under him.”
And the King said: “Go and find out!” They went, and they found that
it was so. And the King said: “Wherefore did you weep when you
saw the wedding?” And he said: “I felt sorry for the groom, for I knew
he would not live another thirty days.” And the King had the matter
investigated, and he found that it was so.
Andréy Mikháylovich Kúrbski. (1528-1583.)
Kúrbski was a descendant of the Yarosláv princes who, as
he was proud of mentioning, derived their origin from the
great Vladímir. At twenty years of age he took part in an
expedition against Kazán, and a few years later he
distinguished himself at the storming of that Tartar city. Iván
the Terrible personally decorated him for his valour in these
and other expeditions against the Tartars, and sent him with
an army to Livonia to operate against the Livonian order. In
1563 Kúrbski lost an important battle against Poland. Fearing
a terrible vengeance from the cruel Tsar, not only for this
defeat, but also for having belonged to the party of Sylvester
and Adáshev, he fled to Poland, where he was received with
open arms by King Sigismund. As soon as he had reached
the city of Volmar, then in the hands of the Lithuanians, he
sent his faithful servant Váska Shibánov with an epistle (here
given) to the Tsar. Iván, upon learning from Shibánov that the
letter he brought him was from the traitor Kúrbski, struck the
sharp point of his staff through the messenger’s foot and
ordered him to read its contents. Shibánov did so, without
expressing any pain, though he was bleeding profusely.
Kúrbski had belonged in Moscow to the circle of the
enlightened churchman Maksím the Greek, who believed in
the importance of profane studies. Kúrbski had acquired
some knowledge of Latin and Greek, which he perfected in
his exile. In Poland he devoted himself to literary studies,
translating Chrysostom and Eusebius, and writing a series of
four epistles to Iván the Terrible, and others to other
prominent personages in Poland. His greatest merit consists
in his having written a History of Iván the Terrible, which is the
first work in the Russian language to deserve the name of
history; for, while the older chronicles gave accounts of
events, Kúrbski subordinated them to a general idea which
runs through the whole work.
Á
THE STORMING OF KAZÁN
If I wrote everything that took place around the city, there would be
a whole book of it. But it is worth mentioning that they used charms
against the Christian army by which they caused a great rainstorm.
From the beginning of the siege, and when the sun just began to
rise, there walked out upon the walls of the city, in our sight, now
their old men, now their women, and they began to howl satanic
words, all the time waving their garments to our army and turning
around in an improper manner. Then there arose a wind, clouds
were formed, however clear the day may have begun, and there
came such a downpour of rain that all the dry places were changed
into bogs and filled with water. And this happened only over our
army, and not elsewhere, so that it did not proceed from the
condition of the atmosphere.
Seeing this, the Tsar was advised to send to Moscow for the wood
from the Saviour’s cross, which is worked into the rood that always
lies near the crown of the Tsar. With God’s aid, they reached
Moscow in a very short time, travelling by water to Nízhni Nóvgorod
in swift Vyátka boats, making the journey in three or four days, and
from Nóvgorod to Moscow by fast relays. When the rood was
brought, into which is worked the wood from the Saviour’s cross on
which our Lord Jesus Christ suffered in the flesh for men, the
presbyters made a procession with Christian ceremonies and
blessed the water according to church use; through the vivifying
power of the cross, the pagan charms disappeared from that very
hour completely....
At the end of the seventh week[115] of the city’s investment, we
were ordered to prepare the next day before daybreak for a general
assault. This was to be the signal: when the powder would explode
and would demolish the wall, which had previously been undermined
and under which forty-eight barrels of powder had been placed.
More than half of the infantry was ordered to the assault, a third of
the army, or a little more, remaining in the field to guard the Tsar. We
were ready early in the morning, as we were ordered, about two
hours before daybreak. I was sent to make the assault at the lower
gate, above the river Kazán, and I had with me twelve thousand
soldiers. At the four sides of the city were placed strong and brave
men, some of them with large detachments.... The Tsar of Kazán
and his senators had been informed about all this, and they were
prepared against us, as we against them....
Then God helped us! My brother was the first to mount upon the
city wall by a ladder, and other brave soldiers were with him. Hacking
and spearing the Mussulmans about them, they climbed through the
windows of the great tower, and from the tower they rushed down to
the large city gate. The Mussulmans turned their backs on the gate
and ran up the high hill to the Tsar’s court, which was strongly
fortified with a high fence, between palaces and stone mosques. We
after them to the Tsar’s palace, even though we were burdened with
our armour and many brave men had wounds on their bodies, and
very few were left to fight against them. Our army which was left
outside of the city, seeing that we were within and that the Tartars
had run away from the walls, rushed into the city,—and the wounded
that were lying on the ground jumped up, and the dead were
resurrected. And not only they, but those in the camp, the cooks and
those that had been left to watch the horses, and others who follow
with merchandise, all ran into the city, not to fight, but to plunder: that
place was indeed full of the richest booty, gold and silver and
precious stones, and it teemed with sable furs and other costly
things.
LETTER TO IVÁN THE TERRIBLE
To the Tsar, glorified by God, who had once been illustrious in

orthodoxy, but who now, through our sins, has become the adversary
of both. Those who have sense will understand how that your
conscience is corrupt even beyond what is found among the
infidels.... I have not allowed before my tongue to utter any of these
things, but having suffered the bitterest persecution from you, and
from the bitterness of my heart I shall speak to you a little.
Why, O Tsar, have you struck down the mighty in Israel? Why
have you delivered to various deaths the generals given to you by
God, and why have you spilled their victorious, saintly blood in the
temples of the Lord, at your royal banquets? Why have you stained
the thresholds of the churches with the blood of the martyrs, and why
have you contrived persecutions and death against those who have
served you willingly and have laid down their lives for you, accusing
good Christians of treason and magic and other unseemly things,
and zealously endeavouring to change light into darkness and to call
bitter what is sweet?
Of what crime have they been guilty, O Tsar, and with what have
they angered you, O Christian vicar? Had they not, through their
bravery, destroyed haughty kingdoms, and made those subservient
to you by whom our forefathers had been once enslaved? Have not
the strong German cities been given to you by God, through their
wise foresight? Is that the way you have rewarded us, poor men, by
destroying us altogether? Do you, O Tsar, deem yourself to be
immortal? Or are you carried away by an unheard-of heresy and
imagine that you will not have to appear before the Supreme Judge,
the godlike Jesus, who will judge the whole world, but especially
cruel tormentors? He, my Christ, who sits on the throne of the
cherubim, at the right of the Supreme Power upon high,—will be the
judge between you and me.
What evils and persecutions have I not suffered from you! And
what misery and torment have you not caused me! And what mean
calumnies have you not brought down on me! So many various
miseries have befallen me that I cannot count them all to-day: my
heart is still oppressed with sorrow on account of them. But I shall
say this much: I have been deprived of everything, and through you I
am exiled from God’s own country. I did not implore with gentle
words, did not entreat you with tearful sobs, did not, through the
clergy, beg for any favour from you, and you have repaid me good
with evil, and my love with an irreconcilable hatred.
My blood, which has been spilled for you like water, cries to my
Lord against you! God sees our hearts: I have diligently searched my
mind, have invoked the testimony of my conscience, have looked
inwardly, have rummaged, and have not found myself guilty before
you in anything. I have all the time led your army, and have brought
no dishonour upon you: by the aid of the Lord’s angel, I have
obtained brilliant victories to your glory, and never have your armies
turned their backs to the enemy, but he has always been gloriously
vanquished to your honour. And this I did not in one year, nor in two,
but through a long series of years, and with much toil and patience. I
always defended my country, and little saw of my parents, nor was I
with my wife. I was continually out on expeditions, in distant cities,
against your enemies, and suffered much want and sickness, to
which my Lord Jesus Christ is a witness. I have frequently been
covered with wounds from the hands of the barbarians, in many
battles, and all my body is covered with sores. But all this, O Tsar, is
as if it had not been, and you have shown me your relentless fury
and bitter hatred which is more fiery than a furnace.
I wanted to tell you in order all my warlike exploits that I had
performed to your honour, my Christ aiding me, but I did not do so,
as God knows them better than man can, for He gives rewards for all
this, nay even for a glass of cold water; besides, I know that you
know all that as well. Know also this, O Tsar, that you will not behold
my face again in this world before the glorious coming of Christ. Nor
imagine that I will forgive you what has happened: up to my death
will I continually cry out against you in tears to the uncreated Trinity
in which I believe, and I call to my aid the Mother of the Prince of the
Cherubim, my hope and intercessor, the Virgin Mary, and all the
saints, God’s elect, and my forefather, Prince Feódor Rostislávich,
whose body is incorrupt, having been preserved for many years, and
emits an aromatic odour from his grave and, by the grace of the Holy
Ghost, causes miraculous cures, as you, O Tsar, well know.
Do not imagine, O Tsar, in your vanity that those who have been
innocently struck down by you, and who are imprisoned and unjustly
banished by you, have all perished; do not rejoice and boast your
vain victory. Those who have been slain by you stand before the
throne of God and ask for vengeance against you; and those of us
who are imprisoned or unjustly banished from our country cry day
and night to God! Though in your pride you may boast of your evil
power in this temporal, transitory world, and invent instruments of
torture against the race of Christians, and insult and tread under foot
the image of the angel, with the approbation of your flatterers and
companions of your table and with the approbation of your boyárs
who make your body and soul to perish ... yet this my letter, which is
wet with tears, I shall order to be placed in my tomb, in order to go
with you before the judgment seat of my Lord Jesus Christ. Amen.
Written in Volmir, a city of my lord, King August Sigismund, from
whom I hope favours and comfort for all my sorrows, through his
royal kindness, the Lord aiding me.
FOOTNOTES:
[115] The siege of Kazán began on August 23, and the city was
taken October 2, 1552.
Iván the Terrible. (1530-1584.)
Iván the Terrible united the qualities of a great ruler with
those of a most cruel tyrant. In his long epistles to Kúrbski he
develops a strong sarcastic vein and defends himself with
specious arguments, quoting copiously from the Bible and the
Church Fathers. He denies his cruelty, but admits the
execution of traitors, who, in his case, form an enormous
category.
LETTER TO PRINCE KÚRBSKI
Our God, the Trinity, who has existed since eternity but now as
Father, Son, and Holy Ghost, has neither beginning nor end; through
Him we live and move about, through Him kings rule and the mighty
write laws. By our Lord Jesus Christ the victorious standard of God’s
only Word and the blessed Cross which has never been vanquished
have been given to Emperor Constantine, first in piety, and to all the
orthodox tsars and protectors of orthodoxy and, in so far as the Word
of God has been fulfillen, they, in eagle’s flight, have reached all the
godly servants of God’s Word, until a spark of piety has fallen upon
the Russian realm. The autocracy, by God’s will, had its origin in
Grand Prince Vladímir, who had enlightened all Russia through the
holy baptism, and the great Tsar Vladímir Monomákh, who had
received memorable honours from the Greeks, and the valiant great
Tsar Alexander Névski, who had obtained a great victory over the
godless Germans, and the praiseworthy great Tsar Dmítri, who had
obtained a great victory over the Hagarites beyond the Don, then it
passed to the avenger of wrongs, our ancestor, the great Tsar Iván,
the gatherer of the Russian land from among the ancestral
possessions, and to our father of blessed memory, the great Tsar
Vasíli, until it reached us, the humble sceptre-bearer of the Russian
empire.
But we praise God for the great favour He has shown me in not
permitting my right hand to become stained by the blood of my race:
for we have not snatched the realm from anyone, but by the will of
God and the blessing of our ancestors and parents, were we born in
the realm, were brought up there and enthroned, taking, by the will of
God and the blessing of our ancestors and parents, what belonged
to us, and not seizing that which was not ours. Here follows the
command of the orthodox, truly Christian autocrat, the possessor of
many kingdoms,—our humble, Christian answer to him who was an
orthodox, true Christian and a boyár of our realm, a councillor and a
general, but now is a criminal before the blessed, vivifying cross of
the Lord, a destroyer of Christians, a servant of the enemies of
Christianity, who has departed from the divine worship of the images
and has trodden under foot all sacred commands, destroyed the holy
edifices, vilified and trampled the holy vessels and images, who
unites in one person Leo the Isaurian, Constantine Kopronymos and
Leo of Armenia,—to Prince Andréy Mikháylovich Kúrbski, who
through treachery wanted to become a ruler of Yarosláv.
Wherefore, O Prince, if you regard yourself to have piety, have you
lost your soul? What will you give in its place on the day of the
terrible judgment? Even if you should acquire the whole world, death
will reach you in the end! Why have you sold your soul for your
body’s sake? Is it because you were afraid of death at the false
instigation of your demons and influential friends and counsellors?...
Are you not ashamed before your slave Váska Shibánov, who
preserved his piety and, having attached himself to you with a kiss of
the cross, did not reject you before the Tsar and the whole people,
though standing at the gate of death, but praised you and was all too
ready to die for you? But you did not emulate his devotion: on
account of a single angry word of mine, have you lost not only your
own soul, but the souls of all your ancestors: for, by God’s will, had
they been given as servants to our grandfather, the great Tsar, and
they gave their souls to him and served him up to their death, and
ordered you, their children, to serve the children and grandchildren
of our grandfather. But you have forgotten everything and
traitorously, like a dog, have you transgressed the oath and have
gone over to the enemies of Christianity, and, not considering your
wrath, you utter stupid words, hurling, as it were, stones at the sky....
We have never spilled blood in the churches. As for the victorious,
saintly blood,—there has none appeared in our land, as far as we
know. The thresholds of the churches: as far as our means and
intelligence permit and our subjects are eager to serve us, the
churches of the Lord are resplendent with all kinds of adornments,
and through the gifts which we have offered since your satanic
domination, not only the thresholds and pavements, but even the
antechambers shine with ornaments, so that all the strangers may
see them. We do not stain the thresholds of the churches with any
blood, and there are no martyrs of faith with us now-a-days....
Tortures and persecutions and deaths in many forms we have
devised against no one. As to treasons and magic, it is true, such
dogs everywhere suffer capital punishment....
It had pleased God to take away our mother, the pious Tsarítsa
Helen, from the earthly kingdom to the kingdom of heaven. My
brother George, who now rests in heaven, and I were left orphans
and, as we received no care from any one, we laid our trust in the
Holy Virgin, and in the prayers of all the saints, and in the blessing of
our parents. When I was in my eighth year, our subjects acted
according to their will, for they found the empire without a ruler, and
did not deign to bestow their voluntary attention upon us, their
master, but were bent on acquiring wealth and glory, and were
quarrelling with each other. And what have they not done! How many
boyárs, how many friends of our father and generals they have
killed! And they seized the farms and villages and possessions of our
uncles, and established themselves therein. The treasure of our
mother they trod under foot and pierced with sharp sticks, and
transferred it to the great treasure, but some of it they grabbed
themselves; and that was done by your grandfather Mikháylo
Tuchkóv. The Princes Vasíli and Iván Shúyski took it upon
themselves to have me in their keeping, and those who had been the
chief traitors of our father and mother they let out of prison, and they
made friends with them. Prince Vasíli Shúyski with a Judas crowd fell
in the court belonging to our uncle upon our father confessor Fedór
Mishúrin, and insulted him, and killed him; and they imprisoned
Prince Iván Fedórovich Byélski and many others in various places,
and armed themselves against the realm; they ousted metropolitan
Daniel from the metropolitan see and banished him: and thus they
improved their opportunity, and began to rule themselves.
Me and my brother George, of blessed memory, they brought up
like vagrants and children of the poorest. What have I not suffered
for want of garments and food! And all that against my will and as did
not become my extreme youth. I shall mention just one thing: once in
my childhood we were playing, and Prince Iván Vasílevich Shúyski
was sitting on a bench, leaning with his elbow against our father’s
bed, and even putting his foot upon it; he treated us not as a parent,
but as a master ... who could bear such presumption? How can I
recount all the miseries which I have suffered in my youth? Often did
I dine late, against my will. What had become of the treasure left me
by my father? They had carried everything away, under the cunning
pretext that they had to pay the boyár children from it, but, in reality,
they had kept it back from them, to their own advantage, and had not
paid them off according to their deserts; and they had also held back
an immense treasure of my grandfather and father, and made it into
gold and silver vessels, inscribing thereupon the names of their
parents, as if they had been their inheritance.... It is hardly necessary
to mention what became of the treasure of our uncles: they
appropriated it all to themselves! Then they attacked towns and
villages, tortured the people most cruelly, brought much misery upon
them, and mercilessly pillaged the possessions of the inhabitants....
When we reached the age of fifteen, we, inspired by God,
undertook to rule our own realm and, with the aid of almighty God,
we ruled our realm in peace and undisturbed, according to our will.
But it happened then that, on account of our sins, a fire having
spread, by God’s will, the royal city of Moscow was consumed. Our
boyárs, the traitors whom you call martyrs, whose names I shall
purposely pass over in silence, made use of the favourable
opportunity for their mean treachery, whispered into the ears of a
stupid crowd that the mother of my mother, Princess Anna Glínski,
with all her children and household, was in the habit of extracting
men’s hearts, and that by a similar sorcery she had put Moscow on
fire, and that we knew of her doings. By the instigation of these our
traitors, a mass of insensate people, crying in the manner of the
Jews, came to the apostolic cathedral of the holy martyr Dimítri of
Selún, dragged out of it our boyár Yúri Vasílevich Glínski, pulled him
inhumanly into the cathedral of the Assumption, and killed the
innocent man in the church, opposite the metropolitan’s place; they
stained the floor of the church with his blood, dragged his body
through the front door, and exposed him on the market-place as a
criminal,—everybody knows about this murder in the church. We
were then living in the village of Vorobévo; the same traitors
instigated the populace to kill us under the pretext (and you, dog,
repeat the lie) that we were keeping from them Prince Yúri’s mother,
Princess Anna, and his brother, Prince Mikhaíl. How is one not to
laugh at such stupidity? Why should we be incendiaries in our own
empire?...
You say that your blood has been spilled in wars with foreigners,
and you add, in your foolishness, that it cries to God against us. That
is ridiculous! It has been spilled by one, and it cries out against
another. If it is true that your blood has been spilled by the enemy,
then you have done your duty to your country; if you had not done
so, you would not have been a Christian but a barbarian:—but that is
not our affair. How much more ours, that has been spilled by you,
cries out to the Lord against you! Not with wounds, nor drops of
blood, but with much sweating and toiling have I been burdened by
you unnecessarily and above my strength! Your many meannesses
and persecutions have caused me, instead of blood, to shed many
tears, and to utter sobs and have anguish of my soul....
You say you want to put your letter in your grave: that shows that
you have completely renounced your Christianity! For God has
ordered not to resist evil, but you renounce the final pardon which is
granted to the ignorant; therefore it is not even proper that any mass
shall be sung after you. In our patrimony, in the country of Lifland,
you name the city of Volmir as belonging to our enemy, King
Sigismund: by this you only complete the treachery of a vicious
dog!...
Written in our great Russia, in the famous, royal capital city of
Moscow, on the steps of our imperial threshold, in the year from the
creation of the world 7072, the fifth day of July.
The Domostróy. (XVI. century.)
The Domostróy, i. e., House-government, is an important
document of the sixteenth century, as it throws a light on the
inner life of the Russians in the time of Iván the Terrible. Its
authorship is ascribed in the extant manuscripts to Sylvester,
the adviser of Iván the Terrible, but it is assumed that he was
only the last compiler of various codes of conduct that were
known in Russia before his day. At least, the whole production
bears the stamp of being a composite work. Two distinct
groups are discerned in it: the first has continual references to
the Tsar and the honours due him; the other deals with a
society whose chief interest is purely commercial, and
appeals to the judgment of the people, instead of to that of the
Tsar. From this the inference is drawn that the first had its
origin in Moscow, the second in Nóvgorod. The morality of the
Domostróy is one of external formalism. To preserve
appearances before God and men is, according to this code,
the chief aim in life.
HOW TO EDUCATE CHILDREN AND BRING THEM UP IN THE

FEAR OF GOD
If God send children, sons or daughters, father and mother must

take care of these their children. Provide for them and bring them up
in good instruction. Teach them the fear of God and politeness and
propriety, and teach them some handicraft, according to the time and
age of the children: the mother instructing her daughters, and the
father his sons, as best he knows and God counsels him. Love them
and watch them and save them through fear. Teaching and
instructing them and reasoning with them, punish them. Teach your
children in their youth, and you will have a quiet old age. Look after
their bodily cleanliness, and keep them from all sin, like the apple of
your eye and your own souls. If the children transgress through the
neglect of their parents, the parents will answer for these sins on the
day of the terrible judgment. If the children are not taken care of and
transgress through lack of the parents’ instruction, or do some evil,
there will be both to the parents and children a sin before God, scorn
and ridicule before men, a loss to the house, grief to oneself, and
cost and shame from the judges. If by God-fearing, wise and
sensible people the children be brought up in the fear of God, and in
good instruction and sensible teaching, in wisdom and politeness
and work and handicraft, such children and their parents are loved
by God, blessed by the clerical vocation, and praised by good
people; and when they are of the proper age, good people will gladly
and thankfully marry off their sons, according to their possessions
and the will of God, and will give their daughters in marriage to their
sons. And if God take away one of their children, after the confession
and extreme unction, the parents bring a pure offering to God, to
take up an abode in the eternal mansion; and the child is bold to beg
for God’s mercy and forgiveness of his parents’ sins.
HOW TO TEACH CHILDREN AND SAVE THEM THROUGH FEAR
Punish your son in his youth, and he will give you a quiet old age,
and restfulness to your soul. Weaken not beating the boy, for he will
not die from your striking him with the rod, but will be in better health:
for while you strike his body, you save his soul from death. If you
love your son, punish him frequently, that you may rejoice later.
Chide your son in his childhood, and you will be glad in his
manhood, and you will boast among evil persons, and your enemies
will be envious. Bring up your child with much prohibition, and you
will have peace and blessing from him. Do not smile at him, or play
with him, for though that will diminish your grief while he is a child, it
will increase it when he is older, and you will cause much bitterness
to your soul. Give him no power in his youth, but crush his ribs while
he is growing and does not in his wilfulness obey you, lest there be
an aggravation and suffering to your soul, a loss to your house,
destruction to your property, scorn from your neighbours and ridicule
from your enemies, and cost and worriment from the authorities.
HOW CHRISTIANS ARE TO CURE DISEASES AND ALL KINDS
OF AILMENTS
If God send any disease or ailment down upon a person, let him
cure himself through the grace of God, through tears, prayer, fasting,
charity to the poor, and true repentance. Let him thank the Lord and
beg His forgiveness, and show mercy and undisguised charity to
everybody. Have the clergy pray to the Lord for you, and sing the
mass. Sanctify the water with the holy crosses and holy relics and
miracle-working images, and be anointed with the holy oil. Frequent
the miracle-working and holy places, and pray there with a pure
conscience. In that way you will receive from God a cure for all your
ailments. But you must henceforth abstain from sin, and in the future
do no wrong, and keep the commands of the spiritual fathers, and do
penance. Thus you will be purified from sin, and your spiritual and
bodily ailment will be cured, and God will be gracious to you.
THE WIFE IS ALWAYS AND IN ALL THINGS TO TAKE COUNSEL

WITH HER HUSBAND
In all affairs of every-day life, the wife is to take counsel with her
husband, and to ask him, if she needs anything. Let her be sure that
her husband wants her to keep company with the guests she invites,
or the people she calls upon. Let her put on the best garment, if she
receives a guest, or herself is invited somewhere to dinner. By all
means let her abstain from drinking liquor, for a drunk man is bad
enough, but a drunk woman has no place in the world. A woman
ought to talk with her lady-friends of handwork and housekeeping.
She must pay attention to any good word that is said in her own
house, or in that of her friend: how good women live, how they keep
house, manage their household, instruct their children and servants,
obey their husbands, and ask their advice in everything, and submit
to them. And if there be aught she does not know, let her politely
inquire about it.... It is good to meet such good women, not for the
sake of eating and drinking with them, but for the sake of good
converse and information, for it is profitable to listen to them. Let not
a woman rail at anyone, or gossip about others. If she should be
asked something about a person, let her answer: “I know nothing
about it, and have heard nothing of it; I do not inquire about things
that do not concern me; nor do I sit in judgment over the wives of
princes, boyárs, or my neighbours.”
HOW TO INSTRUCT SERVANTS
Enjoin your servants not to talk about other people. If they have
been among strangers, and have noticed anything bad there, let
them not repeat it at home; nor should they bruit about what is going
on at home. A servant must remember what he has been sent for,
and he must not know, nor answer any other questions that are put
to him. The moment he has carried out his commission, he should
return home and report to his master in regard to the matter he has
been sent for; let him not gossip of things he has not been ordered to
report, lest he cause quarrel and coldness between the masters.
If you send your servant, or son, to tell, or do something, or buy a
thing, ask him twice: “What have I ordered you to do? What are you
to say, or do, or buy?” If he repeats to you as you have ordered him,
all is well.... If you send anywhere some eatables or liquids, send full
measures, so that they cannot lie about them. Send your wares after
having measured or weighed them, and count the money, before you
send it out. Best of all, dispatch under seal. Carefully instruct the
servant whether he is to leave the things at the house, if the master
be absent, or if he is to bring them back home....
When a servant is sent to genteel people, let him knock at the
door softly. If anyone should ask him, as he passes through the
courtyard: “What business brings you here?” let him not give him any
satisfaction, but say: “I have not been sent to you; I shall tell to him
to whom I have been sent.” Let him clean his dirty feet before the
ante-chamber, or house, or cell, wipe his nose, clear his throat, and
correctly say his prayer; and if he does not receive an “amen” in
response, he should repeat the prayer in a louder voice, twice or
three times. If he still receives no answer, he must softly knock at the
door. When he is admitted, he should bow before the holy images,
give his master’s respects, and tell his message. While doing so, let
him not put his finger in his nose, nor cough, nor clean his nose, nor
clear his throat, nor spit. If he absolutely must do so, let him step
aside. He must stand straight and not look to either side when
reporting the message; nor should he relate any matter not relevant
to the message. Having done his duty, he should forthwith return
home, to report to his master.
Songs Collected by Richard James. (1619-1620.)
Richard James, a graduate of Oxford, had been sent to
Russia to look after the spiritual welfare of the young
Englishmen who were connected with the Merchant
Company. He arrived in Moscow on January 19, 1619, and
started back by the way of Arkhángelsk on August 20 of the
same year. Having been shipwrecked, he was compelled to
pass the winter in Kholmogóry, from which place he left for
England the next spring. He took with him a copy of six songs
that some Russian had written out for him: they are now
deposited in the Bodleian Library. These songs are interesting
as being the oldest folksongs collected in Russia, and as
having been composed immediately after the events which
they describe.
The Song of the Princess Kséniya Borísovna is given in W.
R. Morfill’s Story of Russia, New York and London, 1890.
INCURSION OF THE CRIMEAN TARTARS[116]
Not a mighty cloud has covered the sky,

Nor mighty thunders have thundered:
Whither travels the dog, Crimea’s tsar?—
To the mighty tsarate of Muscovy.
“To-day we will go against stone-built Moscow,
But coming back, we will take Ryazán.”
And when they were at the river Oká,
They began their white tents to pitch.
“Now think a thought with all your minds:
Who is to sit in stone-built Moscow,
And who is to sit in Vladímir,
And who is to sit in Súzdal,
And who will hold old Ryazán,
And who will sit in Zvenígorod,

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Case Studies in Pediatric Dysphagia

CASE STUDIES in Pediatric Dysphagia

Jennifer J. Wilson, MA, CCC-SLP, BCS-S, is a Clinical Assistant Professor

Jennifer J. Wilson, MA, CCC-SLP, BCS-S

Copyright ©2023 by Plural Publishing, Inc.

Typeset in 11/13 Garamond by Flanagan’s Publishing Services, Inc.

All rights, including that of translation, reserved. No part of this publication

For permission to use material from this text, contact us by

Library of Congress Cataloging-in-Publication Data:

Names: Wilson, Jennifer J. (Speech-language pathologist), author.

Chapter 1. Differential Diagnosis in Pediatric Dysphagia 1

Chapter 2. Genetic Syndromes 27

Chapter 3. Aerodigestive Management of Swallowing 57

Chapter 4. Gastrointestinal Diagnoses 79

Chapter 5. Trauma-Informed Care 105

Chapter 6. Pulmonary Diagnoses 135

Chapter 7. Traumatic Brain Injury 161

Chapter 8. Ethical Considerations 179

assessments, and referrals, considering that every case in pediatric dys-

Rebecca Smith, MS, CCC-SLP, CNT, is a clinical educator/adjunct instructor.

Jennifer Wilson ( J): Tell us about your current work in pediatric

supplying resources to students. A lot of them receive little pediatric

to be in a situation like that where someone is handing you what

weather-related issues and travel expenses. Getting an appointment

I am deeply appreciative of the many mentors throughout my academic

Denise Chapman, MS, CCC-SLP

Memorie Gosa, PhD, CCC-SLP, BCS-S

Katlyn Elizabeth McGrattan, PhD

Heidi Liefer Moreland, MS, CCC-SLP, BCS-S, CLC

Rebecca F. Smith, MS, CCC-SLP, CNT

Emily Wojtowicz, MS, RD, CSP, LD, IBCLC

Robert Yost, CRT

Emily Zimmerman, PhD

Chelsea Bell, MA, CCC-SLP

Christopher Bolinger, PhD, CCC-SLP

Allison Tidwell Brown, MS, CCC-SLP, BCS-S

Lori Caplan-Colon, MS, CCC-SLP

Melissa Carrier-Damon, MA, CCC-SLP, BCS

Jamie Fisher, PhD, CCC-SLP

Laura H. Loveless, MS, CCC-SLP, BCS-S, CLC

Jenan Maaz, MS, CCC-SLP, CBIS

Towino Paramby, CScD, CCC-SLP, BCS-S

Julie Raplee, MS, CCC-SLP

Shannon W. Salley, SLPD, CCC-SLP

Bonnie K. Slavych, PhD, CCC-SLP, ACUE

Karin Thomas, SLPD, CCC-SLP

Jan Traughber, EdD, CCC-SLP

Feeding skill Psychosocial

Figure 1–1. Four key domains associated with

dysphagia (Dysphagia Research Society, 2022; Feeding Matters, 2022). Evalu-

DEVELOPMENTAL STAGES IN INFANT AND TODDLER FEEDING

Figure 1–2. Supplemental resources to learn more about normal

the importance of caregiver education and communication in managing

CASE STUDY: EVIE

Case Study Medical History

Episode 1: Evie was referred for outpatient services at 9 months of age

Figure 1–3. Nine-month-old. Figure 1–4. Three-month-old.

She was the product of a 27-week gestational pregnancy with a