Problem-Solving: Pacifiers in the NICU and Aversions


I’m wondering if you have any insight into this. Despite developmental care and a good general awareness of feeding issues that may come down the road, we’ve had a group of chronic babies (<28 weeks at birth, long respiratory course- still on HFNC at 38+ weeks) that go from loving their pacifiers to gagging on them. Of course, it’s not surprising that these chronic, sick babies with arduous courses don’t want their pacifiers (or anything for that matter) in/near their mouths. Is there anything to do earlier in the course to prevent this? Besides developmental care/kangaroo care/making oral experiences as positive as possible/stopping with gagging. Some nurses are asking if we should avoid pacifiers earlier on in the course? Start therapy earlier? I don’t typically intervene in these kids earlier besides education for staff on developmental/kangaroo care (but do see them once stable respiratory wise and we’re thinking about nipple feeding to help guide readiness/nipple selection). Any thoughts? My gut is that we just to be extra vigilant about making sure the baby is ready/looking for/accepting the pacifier and tolerating it all along, encouraging skin to skin vs. actual interventions, but would love your input. Thanks as always for your expertise with these little ones!



You are such a critical thinker. They are so lucky to have you! It’s not the pacifier but rather most likely how the nurses may be inadvertently “giving it” to the infant.

I encourage infant-guided offering of the pacifier when the infant is able from a respiratory and GI perspective to accept it.

That means we need to use the infant’s communication to thoughtfully guide us.

Infant-guided neuroprotective offering of a pacifier means using the infant’s rooting response (by gently moving the pacifier across the infant’s lips) and then honoring the infant’s response. If WOB and/or RR is increased, the infant may not open his mouth and is saying “Not right now. I need to breathe; please wait and ask me again in a little while.”   Too often, caregivers mistake the infant’s not opening his mouth as an indication to just “place the pacifier” or “put the pacifier in”. But it is typically not lack of skill why he doesn’t take the pacifier, but rather he is purposefully not rooting to say, “not right now”. It is an adaptive/compensatory behavior whose meaning may be misinterpreted or misunderstood by some caregivers, especially those who are task -oriented versus infant-guided. GI discomfort may lead to the same response from the infant. Imagine being “asked/expected/”forced” to suck on a pacifier when don’t feel good in your GI system. The infant will remember how he felt. Good intentions to give a pacifier can inadvertently create negative experience.

When caregivers bypass this communication, motor mapping in the brain for the root-to-latch sequence will be altered and maladaptive behaviors can result.

Gagging, grimacing, pushing the pacifier out are all overt refusal behaviors. They look very different then “engagement” behaviors of rooting and focused attention. It really isn’t rocket science.

Perhaps even more worrisome is the stress created by being asked/expected/”forced” to do something that does not feel good right then.

The stress that results, like all NICU stress, has the potential to increase cortisol, change via the amygdala along the HP-axis, and change the architecture of the brain.

This is the pathway to learned refusal behaviors and learning to “hate” the pacifier.

The infant’s communication matters, as does every early experience using his mouth. Neuroprotection can be supported via an infant-guided approach to feeding readiness as well as feeding.



Shaker, C. S. (2018). ‘Mom, You Got This’: Feeding is communication. When we help NICU caregivers interpret what their preemie is telling them during feeding, we support the parent-infant relationship. The ASHA Leader, 23(10), 54-60.

Shaker, C. S. (2017, April). Infant-guided, co-regulated feeding in the neonatal intensive care unit. Part I: Theoretical underpinnings for neuroprotection and safety. In Seminars in speech and language (Vol. 38, No. 02, pp. 096-105). Thieme Medical Publishers.

Shaker, C. S. (2017, April). Infant-guided, co-regulated feeding in the neonatal intensive care unit. Part II: Interventions to promote neuroprotection and safety. In Seminars in speech and language (Vol. 38, No. 02, pp. 106-115). Thieme Medical Publishers.

Shaker, C. (2013). Reading the Feeding: The amount of milk a preemie drinks largely determines readiness for discharge from the neonatal intensive care unit. But just because an infant feeds well today doesn’t mean it will last. In the long term, fostering a child’s consistent, positive response to feeding may be more important. The ASHA Leader, 18(2), 42-47.

I hope this is helpful.


Problem-Solving: Enzymes in EBM that affect thickening


I am currently working in a Level 3 NICU and needing to thicken a baby’s formula to nectar. Baby was previously on fortified breastmilk, but I remember you saying at your course that breastmilk and oatmeal don’t bond. The neonatologist would like evidence. Do you have any suggestions where I can find this info?


It’s likely the Amylase (see below) — while its function when there is purely EBM from the breast is perfect, when additives for thickening are introduced in the EBM, it inhibits binding with oatmeal or rice cereal with the EBM. The oats and the EBM stay separated and therefore the EBM is not thickened.

See Enzymes Found in Breast Milk

There are many different enzymes found in breastmilk. These enzymes play an important role in the health and development of a newborn child. The enzymes in breast milk serve a variety of functions, some of which we do not even know yet. Some enzymes are necessary for the function of the breasts and the production of breast milk, some enzymes help a baby with digestion, and some are essential for a child’s development. Here are the most important enzymes found in breast milk.


Amylase is the main polysaccharide-digesting enzyme. It digests starch. Since babies are born with only a small amount of amylase, they can get this essential digestive enzyme through breast milk.


Newborns can fully digest and use the fat in breast milk because of lipase. Lipase breaks down milk fat and separates it into free fatty acids and glycerol. Newborns get energy from free fatty acids, and lipase makes those free fatty acids available before digestion occurs in the intestines.

Lipase is also responsible for the soapy, metallic smell that refrigerated or previously frozen and thawed breastmilk sometimes has. The cold temperatures and freezing and thawing of breast milk high in lipase can cause the fat in the milk to break down quickly leaving an unpleasant odor. It may not smell good, but the nutritional value is still good.


Protease speeds up the breakdown of proteins. There are high levels of protease in breast milk. It is believed that this enzyme is important for digestion especially during the period right after birth.


Lactoferrin is an iron-binding protein. It helps a baby absorb iron. Also, along with white cells and antibodies, lactoferrin kills bacteria. Lactoferrin stops E. coli from attaching to cells and helps to prevent infant diarrhea. Lactoferrin also prevents the growth of Candida albicans, a fungus. Lactoferrin levels are very high in preterm breast milk and the levels go down as lactation continues.


Lysozyme protects an infant against bacteria such as E. coli and Salmonella. The levels of lysozyme in the breastmilk rise especially around the time babies begin eating solid foods. The increase in lysozyme helps to protect children from germs that can cause illness and diarrhea.

I hope this is helpful.

Problem-Solving: Offering Tastes on NCPAP

Question: I am a Registered Nurse in a regional NICU where we take care of level 2, 3 and 4 infants. I am also co-chair of our dysphagia committee. We are currently doing a swallowing therapy-Therapeutic tastings. The current protocol allows therapeutic tastings to be done with our premature infants > 32 weeks adjusted gestational age that are on respiratory support as high as nasal cpap of 5 cm H2O. These tastings involve small volumes (0.05-0.1ml) of the infants current feeding administered to an infant using a syringe and adapter while infant is sucking on a pacifier, pumped breast or finger. The therapeutic tastings can be ordered to be administered 0.05-0.1 ml every 30 seconds up to a total of 2 ml TID by SLP, nursing staff or parent. Our medical team recently asked the dysphagia committee if it would be safe to do therapeutic tastings on infants that are on respiratory support higher than nasal cpap of 5 cm H2O (not including intubated infants). Is there any research supporting or disputing doing swallowing therapy such as our therapeutic tastings with an infant on respiratory support > nasal cpap of 5 cm H2O?


This question is not answered currently in the literature,  so,  as you have alluded to, caution and critical reflective thinking are essential.

Of course current level of respiratory support required is only one piece of the equation, as GA and other co-existing co-morbidities, WOB, respiratory history (arduous versus non-arduous course) are some key considerations that will affect risk to invade the airway, create undue stress that may adversely affect neuroprotection, and potentially then lead to maladaptive behaviors and aversions.

Take a look at Louisa Ferrara’s paper ( Bidiwala, A. A., Ferrara, L., Islam, S., Pirzada, M., Barlev, D., Sher, I., & Hanna, N. (2016). NEWS FROM THE NICU AND PICU: Effect Of Nasal Continuous Positive Airway Pressure (ncpap) On The Pharyngeal Swallow In Neonates. American Journal of Respiratory and Critical Care Medicine, 193, 1.

Results suggested that the driving force/flow under CPAP appeared to predispose infants to aspiration under fluoroscopy. I wonder if true pacifier dips — via droplet of EBM on pacifier tip— versus using a syringe where bolus size or speed of bolus delivery cannot be as readily controlled — would be a better option. That is what I prefer when the infant appears ready from multiple perspectives to initiate tiny tastes. It offers cautious opportunities for purposeful swallows but with a greater safety margin.

Due to the fragile nature of a premie requiring CPAP, I would have parents not deliver tastes but rather have parents learn along with the SLP or RN —how to recognize respiratory stress cues at baseline and with tastes, state modulation baseline and changes, swallowing behaviors (both audible and visible), postural/sensory-motor baseline and changes, signs of disengagement both subtle and more overt ——while the SLP or RN offers  the tastes and uses anticipatory guidance to explain what infant is communicating.    The complexity of what we are asking the infant to do clearly requires “in the moment” immediate infant-guided responses from the caregiver to optimize safety.  It is worrisome to expect parents to recruit the level of clinical reasoning required in these uncharted waters, as it is with the first PO feeding.  I find parents typically benefit from, and appreciate, learning along with the caregiver to build understanding of the multiple “avenues” of preterm infant communication during tastes as well as future PO experiences.  See Shaker, C. S. (2018). ‘Mom, You Got This’: Feeding is communication. When we help NICU caregivers interpret what their preemie is telling them during feeding, we support the parent-infant relationship. The ASHA Leader, 23(10), 54-60.

Offerings that are arbitrarily every 30 seconds perhaps may not take into account the infant’s ability or desire to continue. Alternatively, infant-guided offerings would best utilize infant communication from moment to moment to determine when an infant may be ready for another tiny taste.

I hope this is helpful.

Research Corner: Aspiration and Dysphagia in the Neonatal Patient

Aspiration and Dysphagia in the Neonatal Patient

Nikhila Raol, Thomas Schrepfer, Christopher Hartnick,

Clinics in Perinatology 45 (2018) 645–660



_ Management of neonatal dysphagia and aspiration should involve a multidisciplinary  effort, including neonatologists, otolaryngologists, pulmonologists, gastroenterologists, and speech-language pathologists.

_ Flexible fiberoptic laryngoscopy and a formal swallow evaluation in conjunction with the speech pathologist should be undertaken in any neonatal patient with dysphagia.

_ Babies born before 34 weeks may have dysphagia owing to a developmental delay.

_ Although the otolaryngologist may recommend acid suppression in patients with laryngomalacia, there is a lack of evidence to support use of acid suppression medications in suspected extraesophageal reflux disease.

_ Addressing anatomic/structural causes of aspiration are indicated when present; however, the vast majority are nonanatomic.