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Pediatric FEES: Protocols, Feeders & Ergonomics in Cardiac Care

Author Olivia Reid covers Pediatric FEES: Protocols, Feeders & Ergonomics in Cardiac Care on BackTable ENT

Olivia Reid • Jun 7, 2024 • 37 hits

Fiberoptic endoscopic evaluation of swallowing (FEES) is a procedure where a thin, flexible tube with a camera is inserted through the nose to assess a person's ability to swallow and to identify any swallowing disorders. When employed for pediatric cardiac patients specifically, FEES demands refined protocols, feeder selection, and procedural techniques. Spearheaded by speech-language pathologist Olivia Brooks, comprehensive safety protocols have been developed, ensuring alignment with cardiothoracic teams' standards and the prioritization of patient health and comfort. Collaborative efforts among interdisciplinary teams have streamlined procedures, emphasizing the importance of skilled feeders, who play a pivotal role alongside the endoscopist and assistants. Ergonomic considerations and tailored approaches, including pre-thickened liquids, optimize procedure efficacy and patient care.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable ENT Brief

•Pediatric FEES protocols demand meticulous preparation, including having essential equipment like blow-by and suction readily available, ensuring patient stability throughout the procedure, and delineating clear criteria for patient eligibility.

•Feeder selection is pivotal for successful FEES testing. Skilled feeders are specialists that are intimately familiar with the baby's feeding dynamics, often speech pathologists or occupational therapists, who collaborate closely with the endoscopist and assistants.

•Specialized techniques, such as the administration of pre-thickened liquids with various flow rates and the use of food coloring for visibility during the scope, enhance procedural efficacy and patient comfort. However, these techniques require continuous refinement and adaptation to each specific case.

•Breastfeeding FEES procedures present unique challenges, requiring close coordination with the mother and innovative methods for introducing food coloring. This highlights the need for ongoing learning in pediatric cardiac care settings.

Pediatric FEES: Protocols, Feeders & Ergonomics in Cardiac Care

Table of Contents

(1) Protocol Development for FEES in Pediatric Cardiac Patients

(2) Ensuring Effective FEES: The Importance of the Feeder

(3) Optimizing Ergonomics & Techniques for Successful Pediatric FEES

Protocol Development for FEES in Pediatric Cardiac Patients

Implementing FEES testing in pediatric cardiac patients requires navigating institutional protocols, creating robust safety plans, and collaborating with interdisciplinary teams. Olivia Brooks, a speech-language pathologist, developed a comprehensive safety protocol that met cardiothoracic teams' requirements while ensuring accurate procedure results. The protocol's key elements include having essential equipment like blow-by and suction available, ensuring patient stability, and establishing clear criteria for patient eligibility.

Detailed procedures for managing transthoracic lines and patient positioning were established through collaboration with cardiothoracic surgeons, respiratory therapists, and nursing staff. Regular recording and review of procedures enhance learning and quality control to facilitate feedback. This iterative process of gaining approval and refining practices not only improves patient care but also fosters a collaborative and educational environment for clinicians, which can help to build trust and ensure that the most appropriate exams are chosen for each patient.

[Olivia Brooks SLP]
Yes. I told him, "Hey, I've done this many. I feel like I'm ready to start trying to do this on my own. How many more would you like to see?" He was in my office 10 minutes later and he signed my competencies. That was the first big step was even figuring out how my institution wanted me to get those competencies signed. Then, the next big step was convincing the cardiothoracic team of this. That was a whole different beast. I would say working with the ENT was much easier, but the cardiothoracic team, and I'm actually very grateful that they did this now. I brought it to them and I explained why, they listened to me and I'm very grateful for that. They heard me and they said, "Okay, here's the deal. We want a safety plan in place. Tell me what your safety plan is going to be." I got to work and I wrote up a protocol and I said, "This is going to be the safety plan. We're going to have blow by. The patient's going to have worked with me before, so I know that they're stable enough to do this. We're going to have blow by available. We're going to have suction available. A nurse is going to be in a room. There's going to be two skilled clinicians in the room, an endoscopist and a feeder. This is what we were going to do if we needed to abort the study." I outlined just some criteria for patients that were appropriate. They need to be weaned. We just made a decision to do two liters or less, unless that's acting as CPAP, like the baby's very small, but I wouldn't do a FEES on an infant like that anyway. We just said two liters. They couldn't have any transthoracic lines in place. Those needed to be removed. They were stable and working with us before and they were able to get out of bed. We had a whole list of criteria.

Then from there, they said, "Okay, this looks good. We like your plan. We want to come watch 10." We want to be present for the first 10 that you do. We just want to see. I think that they watched one, maybe two. Then they were like, "Okay, you're fine. Go on with it." Once they signed off on it, and now we have all these nice, really helpful protocols that I've used to train other speech therapists on how to do this. It's been a nice snowball effect. We have two other pediatric clinicians now who are endoscopists and do wonderful work, and I feel like it's helped us all grow. I'm grateful to the physicians that really took me under their wing. I think it was a labor of love in the beginning, but now I hope they feel like it's paying off.

[Dr. Gopi Shah]
Oh, I'm sure.

[Olivia Brooks SLP]
It's helpful they're not having to run up from the OR.

[Dr. Gopi Shah]
Yes. It's good for the baby, right? It's better care. When you were learning to scope initially, were all your scopes recorded? Could you go back and look at them? Was it not only just the physical passing of the scope, but also assessing vocal cord mobility and laryngeal function as well in the initial training period?

[Olivia Brooks SLP]
When I was practicing with ENT initially, we recorded the laryngoscopy part?

[Dr. Gopi Shah]
Yes. That's what I mean.

[Olivia Brooks SLP]
Yes. I actually did do that when I was doing research at the Aerodigestive Research Core for that year, we actually videoed me scoping everyone too, so that we could time it up for research purposes. I will say that it was extremely helpful to me to go back and watch myself because I certainly realized some issues with my posture. I changed how I was doing it a little bit because I was able to go back and watch and see how I was holding it. I would recommend that you do that even though I didn't do it initially. So I like to know what I'm looking at, but I also feel very strongly that as a speech pathologist, my scope of practices and not overstepping that.

Yes, in answer to your question, certainly we would go over the videos together with ENT because even still now our images are sent to a shared ENT folder for ENT to review should they need to. I don't diagnose anything. I think that that's an important distinction. It's just something that I've had to really talk with our teams about because now they only want FEES sometimes and they'll say, "Can you just tell us what the airway looks like?" I'm not an airway physician. That's not my scope. ENT, if you'd like for them to be consulted and review the images, they can give a diagnosis. I cannot give a diagnosis. I can describe what I see, so that's what I do. We would go over the videos together and talk about it. I was given the opportunity to ask questions and that was very, very helpful because even just noticing little things like, am I suspicious that it's not a vocal fold paralysis, but there might be some laryngomalacia or something in there that I think ENT might want to just be alerted to or whatever. I think that it's very helpful that I am able to see those things and not send frivolous referrals to you guys, things that actually you want to see and it's a good use of your time as well. I was given that opportunity and I think it was good, but as far as my report and all that, I'm only commenting on swallow function and I can describe what I see, but no diagnosis other than dysphagia, if it's there.

[Dr. Gopi Shah]
If there's something that you're questioning or if the team wants to question, there's a shared folder of all the FEES that are recorded. That way an ENT can look at it?

[Olivia Brooks SLP]
We only put in the consult for ENT into the shared folder. Not all of them go in. I'll be honest. I'm a little bit privileged because my partner's a peds ENT, so if sometimes if I'm on the fence about something, I'm able to like upload it and just say, "Hey, can you just take a quick look at this whenever you get a second and tell me if you feel like this warrants a consult to you before I throw a big stink about it and get everybody involved." I don't have to do that as much anymore because I'm learning as I go. We only upload them to that shared drive if we want ENT to take a look at it. Not all of them get that because we do have the protocol on the cardiac ICU and a lot of those scope exams are fine. They're functional. Their airway is very stable. They're feeding just fine. They're not aspirating. We don't clog it up with things like that.

Listen to the Full Podcast

Implementing FEES for Infants in CVICU & NICU with Olivia Brooks, SLP on the BackTable ENT Podcast)
Ep 165 Implementing FEES for Infants in CVICU & NICU with Olivia Brooks, SLP
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Ensuring Effective FEES: The Importance of the Feeder

In pediatric FEES procedures, the role of the feeder is crucial to the success and safety of the evaluation. The feeder must be highly skilled and intimately familiar with the baby, typically leading to the selection of a speech pathologist or occupational therapist to perform the feeding. The feeder collaborates with the endoscopist and an assistant, forming a three-person team that ensures precise execution of the procedure. Parents are involved post-procedure; this enables the baby to be soothed and bond with the family, while simultaneously allowing clinicians to review findings and formulate recommendations. This structured approach balances the technical demands of the procedure with the emotional needs of the family, enhancing both the clinical outcomes and the patient-family experience.

[Dr. Gopi Shah]
The feeder can be another nurse, a parent, another speech pathologist? Who's the feeder?

[Olivia Brooks SLP]
That's a great question because I'm very picky about that.

[Dr. Gopi Shah]
Yes, you're the endoscopist, so who's the person feeding? Because that's your partner in doing this.

[Olivia Brooks SLP]
Yes. We've found what works best, this may be different for different institutions and different endoscopists. I'm very picky about who the feeder is. I think it's the hardest job on the team at that moment. I want that feeder to be a very skilled feeder who knows this baby intimately and has been working with the baby. What we have found, what works best for us, 9 times out of 10, it's going to be either a speech pathologist or an occupational therapist. We usually have three people on our team. We have the feeder, who's the primary feeding therapist for that baby, that would be either a speech pathologist or an occupational therapist, endoscopist, and we also have an assistant, which can be the nurse or a lot of times med students like to come in and watch and they'll help, or a graduate student or something like that who can help us hit record. We do pacifier dips of sucrose sweeties or breast milk like two minutes before we pass the scope just for that very short-term analgesic effect. They help with all of that and keeping track of what strategies we've tried and when and time stamping and all of that.

We need at least three people and I'm very picky about who the feeder is. There's probably some controversy with this. I try not to let parents feed if it's at all possible. I just find that they get a little bit overwhelmed by it and we're really providing a lot of containment during the feeds and the positioning and the ergonomics is so important. It takes longer to set up for it than it takes to actually do it oftentimes. They want to rock and shush. What works for me is I explain all this to the parents. I like for them to be there, though, in the room because part of our protocol, which we also had like this whole other leg to it, which was neurodevelopmental care was, immediately after the FEES, the feeder gets up, I back up, the parent sits down, we hand the baby and they do some skin to skin and calm and like set to a pacifier. I tell the parents that's their job. The babies might cry for a minute. Sometimes they even don't, but they might cry. We're going to ask them to eat. We're going to ask them to run a little bit of a marathon here with us and work with us so we can get some information. As soon as we're done, this is what's going to happen. I'm going to get up and back up. Julia or whoever's feeding is going to stand up and I need you to come in and sit and hold the baby and calm them for at least 15 to 20 minutes.

That also gives me a little bit of time to review my images and get everybody nice and calm and in a good state so that I can talk to the family about what I saw, what my recommendations are going to be, if we're going to get ENT involved, if we're going to start feeding, if we're not going to start feeding. I think that it gives them some ownership still without having to let them feed at that time. I think it's just hard with all the lines and everything too. It's a different beast.

Optimizing Ergonomics & Techniques for Successful Pediatric FEES

Ergonomic optimization and tailored approaches to various feeding methods contribute to successful pediatric FEES testing. Olivia Brooks, SLP underscores the importance of having all necessary materials (e.g. pre-thickened liquids and various nipple flow rates) ready beforehand to facilitate smooth transitions during the procedure. The use of food coloring increases visibility during the scope. Filming procedures can improve technique by highlighting ergonomic adjustments that can be made to prevent strain and ensure precision.

When parents wish to breastfeed their infant during the FEES procedure, unique challenges often arise. These include the need for close physical coordination with the mother and creative methods for introducing food coloring. While less common, these procedures can be refined through provider practice and by adapting techniques to each specific case.

[Dr. Gopi Shah]
In terms of tips and tricks, I think that the point about the ergonomics is important. I think that the experience of filming yourself, I don't think we do that ever or enough. If anybody's ever even done once, I'm sure if somebody filmed me even doing a tonsil, they'd be like, "Look at your bed could be a little bit higher. Your neck is completely cracked over. How are you holding--?" I'm short. I've been doing it forever. The ergonomics and filming yourself, what are their tips and tricks? Is there a certain way you like to have your baby swallowed? Is there a certain side of the bed that you stand on? Anything like that that seems to help you?

[Olivia Brooks SLP]
Sure. We have everything set up ready to go as far as what bottles we're going to use. I'll have nipples lined up with different flow rates so that very quickly we can switch things out. I'll pre-thicken some bottles. Usually, I'll have an ounce of thin liquid. Then, depending on if it's breast milk or formula, for formula I'll thicken that up in a little bit of a larger quantity and then I can toss it later. Breast milk, I tend to be a little bit more protective of. I don't want to thicken and then not use it and have to toss it, but we will thicken up a little bit using a product called Gel Mix, which I really like, and nectar. We go thin, slightly thick, mildly thick. Those are the new terms, or you could say thin, half nectar, nectar. We have a little bit of organic food coloring that we put in, like a dye. I go white, green, white. I just think the white shows up really nicely on the scope, so I'll just dye it, make it a little bit more of a brighter white. I go green for the slightly thick, so there's some contrast. I go white again if we have to go to full nectar, because at that point, we can see if there's something new. That's how I set it up. Obviously, we've worked with this baby before, so we know what nipples and positions have been working well clinically, and we just start there.

[Dr. Gopi Shah]
What about the baby that's breastfed, the baby that ended up with some sort of blue cyanotic event at home, newborn, maybe born 37 weeks gestation, now is 10 days, was getting breastfed at home? For the bedside FEES, we've mentioned a feeder and bottles, but do you ever do these with mom, like breastfeeding FEES?

[Olivia Brooks SLP]
We have. It's not as common, I would say, but we have done them. I'm still working out the best way, I think, to do those. They're a little bit more challenging for me, I think, just because we don't do them as often. The first few I did with ENT were really rough, to be honest, and I really sat down afterwards, and I was like, I don't know how to do this well. I don't know how to get my position right to where I'm not irritating the baby so much, and the mom's very stressed. It didn't feel as natural to me as the bottle-feeding one does. I think we've gotten a little bit better about that. I just tell the mom, listen, we're going to be good friends. I'm going to be up in your business, and we're going to get through it together, and they're usually laughing. They'll be all right with it. I almost just straddle her, and her legs go, for lack of saying it nicer, between mine, and I just scoot right up. Again, depending on mom's breast size and shape and how little the baby is, if they can latch first and go, and then I insert the scope, I think that works a little bit better. If that's not working, then I just try to have the baby as close to mom's breast as we can.

What I do is I have the assistant, whoever's helping me out, drop a little bit of the food coloring from a syringe on mom's nipple right in the corner of the infant's mouth whenever the child does start to nurse, and I just manipulate the scope to get to where I can see the best view. We do them, yes, in answer to your question. It takes a little bit more finesse, finagling, and it's not as common, so I'm not as skilled, I feel like, in that. I think we're learning as we go with those, but we can, and we do them. I've had some really good ones, and I've just had some ones that just didn't work at all.

Podcast Contributors

Olivia Brooks, SLP discusses Implementing FEES for Infants in CVICU & NICU on the BackTable 165 Podcast

Olivia Brooks, SLP

Olivia Brooks is a pediatric speech-language pathologist at UF Health in Gainesville, Florida.

Dr. Gopi Shah discusses Implementing FEES for Infants in CVICU & NICU on the BackTable 165 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2024, April 2). Ep. 165 – Implementing FEES for Infants in CVICU & NICU [Audio podcast]. Retrieved from

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.



Implementing FEES for Infants in CVICU & NICU with Olivia Brooks, SLP on the BackTable ENT Podcast)



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