I have been using the Ross (cleft palate) nipple most recently with my newborn cleft babies…

Q & A Time with Catherine


I have been using the Ross (cleft palate) nipple most recently with my newborn cleft babies. It seems to be working really well. I feel pressure to use the Habermann since we have a few boxes in stock but I never seem to have luck with that bottle. Does anyone else seem to have trouble with the Habermann, or is there something that I could possibly be doing wrong?


Over tightening can “crimp” the disk and obstruct flow and collapse the nipple. Just gently hand-tighten the ring, don’t turn it hard. It gets easier to do the more you use it ūüôā

Also the Habermann can be used very effectively without squeezing of the teat. I have had newborns with complete cleft of the soft and hard palate, such that all that was left was the boney nasal septum; they can effectively get flow via their using only their own active compression.

Know that when we squeeze to deliver flow it is likely very challenging to deliver the right amount, even with attending very carefully to the infant’s cues to guide us. That makes it hard to avoid “overfilling the valleculae” and increases risk for bolus mis-direction toward the airway. The long soft palate of the newborn actually sits in the vallecular space, to help create a “bolus accumulation” site that helps “contain” the fluid which, in the normal newborn, is actively “driven” into the valleculae. When the soft palate is cleft, that “seal” is breeched and squeezed flow has the great potential to be beyond the infant’s capacity and to move toward the airway. This has the potential to occur even when we try our best to limit the squeeze/bolus size, since we cannot “see” in the valleculae at bedside to objectively know that the valecullae are getting too full. Let the infant self-limit the flow rate by not squeezing. You can then use co-regulated pacing as needed if the infant “gets ahead of himself”. One of the benefits of the Habermann is that when baby stops sucking, there is no flow.

I much prefer the Habermann to other feeding devices for our infants with cleft palate for this reason.
Safety is always enhanced with infant-guided regulation of flow rate.

Q & A Time: Use of PAL in NICU

I am wondering if any NICU therapists are familiar with or are using the PAL (Pacifier Activated Lullaby). It is supposed to stimulate NNS by playing music while the infant sucks. One of our nurses recently met with the company and is interested in learning more about it. I have not heard of it before this and after looking at their website am not convinced it is worth pursuing. I just wanted to see if anyone else out there has heard of this or has any thoughts. Any input would be greatly appreciated. Thanks!

We must all be thoughtful as we evaluate devices that are designed or marketed to develop a skill. It is the thoughtful use of a modality, or the thoughtful decision not use it, based on the clinical assessment of our patient and the evidence, that should be our guide, both in the NICU or in any other level of care in which SLPs are a part of the team.

My NICU clinical experience¬†for over 28 years suggests that PAL (Pacifier Assisted Lullaby) ¬†is not an answer for the feeding/swallowing problems preterm infants present, and may actually inhibit functional skill (i.e., feeding). The issue for preterm infants is more complex than a “sucking problem.” Feeding problems in the NICU are rarely so simple, though sometimes a “poor suck” is unfortunately perceived as the reason for many of them. Learning to feed, both effectively and safely, is a complex, multifaceted¬†challenge for preterm infants.1

I have been part of the team in two large level III NICUs, and many of those babies have been extremely preterm. Many have respiratory distress syndrome (RDS) or CLD (Chronic Lung Disease), requiring intubation and ventilation, and/or need supplemental oxygen in the course of their recovery. We have not observed a direct detrimental effect on non-nutritive suck (NNS). These infants typically demonstrate effective non-nutritive sucking when ready to initiate bottle feeding, with respiratory issues being the paramount barriers. We have found that the NNS typically emerges with development and positive support during care. For all infants, our nurses provide excellent oral care, including developmentally appropriate hand-to-mouth, rooting and pacifier activities, to support development of non-nutritive sucking. For infants with delays in onset of oral feeding due to medical status or those profiled as likely to be high-risk fragile feeders, the speech-language pathologist is added to the team to provide positive early pre-feeding and graded swallowing experiences. This helps the infant make the transition to nutritive sucking more safely and effectively.2

The challenges preterms encounter in learning to feed are most often the direct sequelae of residual respiratory problems. These problems (e.g., tachypnea, increased work of breathing, compensatory breathing behaviors, breath-holding) jeopardize the coordination of sucking, swallowing and breathing. 1  This can lead to respiratory fatigue and incoordination, or indeed adverse events such as choking, coughing and color change. Even infants with excellent NNS can have significant problems learning to suck nutritively because their drive to suck is often stronger than their physiologic sense of oxygenation.3

Very often the co-morbidities of early gestation, lower birth weight and attendant respiratory sequelae make feeding a challenge. The NNS, for which PAL was developed, has not been the issue delaying discharge.

It is also  important to recognize that the NNS and the nutritive suck are very different in their rate and rhythm due to the addition of fluid with nutritive sucking. This renders non-nutritive and nutritive sucking different developmental skills. Lingual patterns on ultrasound have shown significantly greater displacements and excursions when a preterm infant was sucking nutritively vs. non-nutritively on a pacifier.4

The NNS is not in itself a predictor of nutritive success (i.e., bottle feeding), research has found.5
NNS is just one of several domains that require consideration when contemplating the introduction of oral feeding. While found to be helpful, typical non-nutritive interventions have not been shown to decrease length of stay.6

A recent study reported that a non-nutritive stimulation program in an NICU did not result in earlier weaning from an nasogastric (NG) tube or earlier discharge when compared to similar infants without that intervention.7

In addition, PAL is designed to foster, and has as its outcomes, longer sucking bursts. Longer sucking bursts¬†are problematic for the preterm. Longer sucking bursts may inadvertently, and likely do, increase WOB and overall respiratory effort. This “drain” on the infant’s respiratory reserves can have detrimental effects on the functional skill of feeding,8¬†¬†¬†as¬†PAL is often provided just prior to a feeding.

Also, during PAL, it is likely¬†at the preterm infant is not able to stop on his own at the appropriate junctures to take a series of deep breaths. This is directly related to immaturity, i.e. the drive to suck can inhibit the drive to breathe in the preterm, as he cannot register changes in CO2 versus O2, which can be a by-product of continuous sucking.¬†So we often see a continuous sucking pattern with the pacifier and with PO feeding.9 ¬†While continuous sucking may sound like a hallmark of skill, in the preterm infant it can destabilize the autonomic system, lead to breath-holding or insufficient breaths, which can lead to desaturation, and potentially a cascade of events leading to decompensation. So sucking, faster sucking or engaging in longer sucking bursts, is¬†not necessarily good for the preterm and typically is not. Sucking can’t be looked at in isolation, as it is part of a dynamic physiologic event that has multiple system implications/effects. 10 ¬†¬†When the focus is on sucking itself, i.e. with PAL, we are not providing the preterm with the careful support required to integrate breathing with sucking. Then sucking activities provided can actually be detrimental to motor-learning, and potentially increase stress on a physiologic level.11 ¬†This can then lay down neural pathways that, instead of facilitating positive learning, may move the infant away from learning to feed.12

While it may seem to some that enhancing sucking can be the answer for feeding issues that delay discharge, it is just not that simple. NICU infants learning to feed require dynamic, infant-guided supportive strategies during both pacifier sucking and during feeding, based on watchful vigilance and continuous feedback from the infant. The focus is on physiologic stability, active participation of the infant, and coordination of sucking with swallowing and breathing.5   This approach is more likely to promote readiness for  and eventual swallowing safety, support adequate nutrition, and result in the earlier discharges we have seen in the NICUs I have been fortunate to work in.

As you are undoubtedly aware of, supporting successful feeding for preterm infants goes way beyond sucking. For those infants who indeed do have “sucking” problems, then the involvement of the SLP, who can problem-solve with reflective/critical thinking, is far better than a referral for PAL, in my opinion.


  1. 1. Shaker, C.S. (2013) Reading the Feeding. The ASHA Leader – American Speech-Language-Hearing Association.
  2. 2. Shaker, C.S. (2013) Cue-Based Co-regulated Feeding in the NICU: Supporting Parents in Learning to Feed Their Preterm Infant. Newborn and Infant Nursing Reviews (2013) 13 (1): 51-5
  3. Shaker, C.S. (2012) Feed Me Only When I’m Cueing: Moving Away From a Volume Driven Culture in the NICU. Neonatal Intensive Care, Journal of Perinatology-Neonatology, 25 (3) May-June, 27-32.
  4. Miller, J.L., Kang, S.M. (2007).Preliminary ultrasound observation of lingual movement patterns during non-nutritive versus non-nutritive sucking in a premature infant. Dysphagia, 22: 150-60.
  5. Lau, C., Kusnierczyk, I. (2001). Quantitative evaluation of infants’ non-nutritive and nutritive sucking. Dysphagia, 16: 58-67.
  6. Fucile, S., Gisel, E.G., Lau, C. (2002). Oral stimulation accelerates the transition from tube to oral feeding in pre-term infants. Journal of Pediatrics, 141: 230-36.
  7. Bragelian, R., Rokke, W., Markestad, T. (2007). Stimulation of sucking and swallowing to promote oral feeding in premature infants. Acta Paediatrica, 96: 1430-32.
  8. Thoyre, S.M., Shaker, C.S., Pridham, K.F. (2005). The early feeding skills assessment for preterm infants. Neonatal Network, 24: 7-16.
  9. Shaker, C.S. (2010) Improving Feeding Outcomes in the NICU: Moving from a Volume-Driven to an Infant-Driven Approach. American Speech, Language, Hearing Association. Swallowing Disorders Division 13 Perspectives – Oct
  10. Shaker, C.S. (1999) Nipple feeding preterm infants: An individualized, developmentally supportive approach. Neonatal Network, 18(3), 15-22.
  11. Smith G.C., Gutovich, J. et al (2011) Neonatal intensive care unit stress is associated with brain development in preterm infants .Annals of Neurology. 70(4), 541-549.
  12. Browne, J. V., & Ross, E. S. (2011). Eating as a neurodevelopmental process for high-risk newborns. Clinics in Perinatology, 38(4), 731.

Catherine S. Shaker, MS/CCC-SLP, BRS-S
Board Recognized Specialist – Swallowing and Swallowing Disorders


Q & A Time: Services in the Pediatric Intensive Care Unit

Q & A Time: Services in the Pediatric Intensive Care Unit

QUESTION: I have a general question about providing services in the Pediatric ICU. It has made sense to me to provide support for the development of sucking and swallowing skills for infants in the NICU. Many of these babies are not even eligible for discharge until they are nipple feeding or at least stable on a feeding tube. But this seems different to me than the situation in the ICU. I’d like to know how this concept for babies translates to the ICU for older kids and adults.

If a person has lost swallowing skills due to illness, surgery or a traumatic brain injury it would seem to me that the individual would be pretty sick if he or she were in the ICU. It also makes intuitive sense to me that during the time in the ICU that the person’s physical body would be focused 100% on just getting well and more stable in physiological functions. Most of the friends and relatives I’ve seen in the ICU don’t have the energy or focus for an external swallowing rehabilitation focus. There also seems to be some natural return of function as their overall health improves. The therapy for swallowing seems to come later when the person is well enough to go to a step-down unit etc. With these observations, I don’t understand why a therapist would be assigned to work on swallowing function when the person is in the ICU. I’d appreciate it if you could help me understand the rationale for working with someone who is sick enough to be in the ICU. Thanks.
ANSWER: Our intensivists and nurses appreciate our involvement to evaluate, treat, provide consultation and education, and attend rounds to problem-solve the complex interaction of systems and their impact on swallowing safety and communication. The patients present with a wide variety of issues and etiologies, including cardio-respiratory, neuro, airway, GI, neuro-motor, and/or sequelae from prematurity that impact critical decisions that need to be made during their stay in PICU. The challenge of course is to provide our input and our services in the context of the infant’s/child’s ever changing medical status through very close interaction with the medical team and adjust our plan of care accordingly from day to day, moment to moment. We must carefully consider not only what to do, when to do it, but what not to do. Reflective thinking, caution and respect for the “bigger picture” must always prevail.

Our expertise can improve the likelihood that decisions made minimize adverse consequences and may indeed reduce LOS. That may mean helping the medical team to complete the differential and sort out key issues, evaluating a patient for readiness for direct therapy, assessing to help determine whether to feed orally and the safest way /diet to do so, or when not to feed orally but rather initiate SLP involvement to establish readiness, normalize the oral-sensory system during/after periods of NPO, and/or facilitate key components of oral-motor control/swallowing when medical stability permits, provide assessment of cognitive-communication skills that helps a physician to complete his neuro differential, direct therapy to improve skills and assist MD with prognosis, strategies for RNs to best communicate with the child or support the infant’s emerging communicative intent. We follow these infants and children as they transfer to units such as Pediatric Critical Care or Pediatric Rehab, and provide input regarding readiness for discharge and post-discharge needs. Family and staff education, some of it direct, some of it incidental, is a big part of our contribution to the infant’s/child’s care.

PICU, as well as NICU, are by far wonderful and fulfilling environments to work in, as we have the opportunity to be an essential part of the care team, learn something new every day through both these interactions with the team and our little patients and their families, and provide the unique input our training and expertise allow.