The shape of the palate is determined by genetics and in utero by the
tongue, which forms and spreads the roof of the mouth.  Mendalian forces
(genetic syndromes) can cause malformed palates, perhaps in concert with
environmental issues poorly understood as yet.  In the case of preemies with
high arched palates and breathing disorders, is this genetic, or is it a
result of an infant whose prematurity hasn't allowed for the tongue to
finish spreading the palate?  The maleability of the palate in preemies is
clear when you look at the erosion caused by tube feeding. The feeding tubes
and breathing apparatus may do more damage than pacifiers as they depress
the tongue away from the roof of the mouth.  And yet we must have them
because we don't really know how else to provide nutrients for these babies
prior to oral feeds.  Remember, these are babies who 30 yrs ago wouldn't
have survived, so we don't yet know everything we need to know about their
optimal care.

In thinking about how to use tools and thinking about what needs to be
accomplished by the use of the tool (i.e.  something like a rationale!)
perhaps pacifiers could be more specifically chosen to do a job, and more
specifically engineered in terms of shape.  For instance, why are they so
often hollow?  Resistence against pressure is the basis of exercise.  I
select air-filled or gel-filled pacifiers exclusively when using them as
tools to strengthen suck for an infant who is functionally unable to
breastfeed.  I want them to do "push-ups" on something when sucking
non-nutrively so they will strengthen jaws, tongue, cheeks and palate.

 If I have a baby who cannot breastfeed, and I am looking at a several
week-long process to bring the child to breast, I move in gradual stages
that typically begins with a mom and baby who already are bottle feeding.  I
specifically avoid using bottle teats that are "shaped" like the Nuk or the
Medela teat.  I want the baby to use his or her tongue and palate to shape
the bottle teat just as they would use them to shape the breast into a
compressed teat (as the ultrasounds demonstrate).  My "ideal" bottle teat
would have a wide base, a teat length of about 2.5 cm with a bit of
elasticity, and a broad shaft that isn't too collapsable.  I am often
working with a Cranial Sacral Therapist, or PT/OT or speech path during this
process.  It goes without saying we are aggressively working on milk supply
and that baby is skin-to-skin and trying at breast at every feed.

My job would be easier in these remediations with better tools.  Why are
pacifiers so narrow?  The bases should be designed with progessively larger
diameters to help the lips become increasingly adept at closing around
flared objects (like a breast).  The shaft should also be broader, so that
if a child is not yet nursing, and has no elastic breast to shape, or is
premature, and has weird shapes in the mouth, the pacifier could broaden and
spread the palate better.  The lengths, also, should be graduated, and be a
good fit with what I call the palatal reach (i.e. the distance between lip
closure and the junction of the hard and soft palate).  One certainly
doesn't want to put objects into the mouth that repeatedly trigger a gag,
etc.

There is a risk in even talking about this because people get the idea that
I am discussing all babies instead of specific strategies to remediate
problems in  compromised babies.  Normal babies typically aren't much
interested in sucking on plastic.  Why should they be?  They can nurse! They
can breathe!  But when you see dysfunctional kids (which I define as the
infant who is UNABLE to breastfeed) you have to start somewhere habilitating
their oral function.  Reasonable practitioners from other disciplines use
tools to do this, and they include pacifiers.  I just happen to think we
haven't designed these tools as well as we could.

Barbara Wilson-Clay, BSEd, IBCLC
Austin Lactation Associates
http://www.lactnews.com

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