Feeding Issues & Methods

Common Feeding Issues in the NICU

  • Difficulty coordinating sucking, breathing, and swallowing
  • Feeding for long periods at a time
  • Tires before finished feeding
  • Oral sensory problems
  • Aspiration with oral feedings
  • Medical or physical conditions

It is difficult for some premature infants to take in adequate nutrition via oral feedings, because of their inability to coordinate suck swallow patterns and coordinate breathing. Because of these problems feedings may last too long. If a feeding lasts longer than 30 minutes it may tire the infant resulting in a loss of energy. In this case supplemental tube feedings are commonly used to provide the nutrients needed by the premature infant.

There are different methods to include supplemental tube feedings. One is to provide oral feedings and then follow that up with a bolus tube feeding every 3-4 hours. Another method is to use oral feedings only during the day and supplemental continuous tube feedings provided during the night. There are several factors including aspiration risk and respiratory status that need to be considered by the medical team and family before choosing the method of supplemental feeding that is appropriate for the infant. (Edelstein & Sharlin, p.171)

Infants should be able to receive an appropriate amount of milk within 30 minutes, so that they do not expend more calories than they are taking in. In addition they should be able to take in enough calories to keep them content for a 3-5 hour periods and show adequate growth and development.

Infants usually need to be off ventilator support before oral feeding can begin. To begin oral feedings it is recommended that the infant have a resting respiratory rate less than 70 breaths per minute. Once oral feeding has commenced the infant’s respiratory rate should not exceed 80-85 breaths per minute or oral feeding should be stopped. (Arvedson & Brodsky, 2002, p 304)

A premature infant may be ready for oral feedings as early as 32 weeks, depending upon the infant’s development and other complications they may have. Most premature infants are able to be completely feed orally by 37 weeks gestation.

Symptoms that Require Referral for Dysphagia Evaluation

  • Frequent respiratory infections – possibly due to silent aspiration
  • Apnea/ disrupted breathing during feedings – color change to blue or pale can be signs of silent aspiration
  • Spitting up or vomiting frequently – possibly due to GERD
  • Food or liquids coming out of the nose during or after a feeding – could be due to inadequate velopharygeal closure or Cleft Palate.
  • Uncoordinated sucking – due to tongue, cheek instability, sensory problems, or postural problems.
  • Problems with lip seal or latching on – may be related to breathing or oral sensory issues
  • Weight loss – not receiving adequate nutrition
  • Discomfort, increased fussiness, irritability, and/or arching during feedings
  • Lethargy during feedings, or tires easily and has difficulty finishing a feeding in 30 minutes
  • Abnormal oral-motor anatomy or physiology: lips, tongue, jaw, or palate
  • Choking, gagging, or recurrent coughing during or after a feeding
  • Recurrent vomiting during or after a feeding

(Edelstein & Sharlin, 2009, p.172)

Infants who have sensory awareness or difficulty with the coordination and timing of their breathing and sucking pattern are at risk for aspiration. These problems can lead inefficient airway protection and aspiration. Infants with these problems may also experience pooling of the bolus in the sulci, valleculae and or pyriform sinuses. With pooling the bolus appears to have been swallowed, but may only cause a delay in the penetration of the airway. (Morris, 1998)

A study published in Pediatrics showed that more than half of infants who are suspected of having dysphagia experienced laryngeal penetration, aspiration, or nasopharyngeal backflow. The infants tended to experience the above mentioned problems after multiple swallows, with premature infants displaying more signs of nasopharyngeal backflow. (Newman, Keckley, Petersen & Hamner, 2001)

Feeding Methods in the NICU

How to determine oral feeding readiness

  • Position/posture- flexor
  • Neck, trunk & shoulder stability
  • Anatomically set for sucking
  • Strong suck strength
  • Can maintain lip seal
  • Cheek stability
  • Jaw stability for repetitive suck
  • Hunger and thirst signals
  • Neurologic status is organized
  • Rhythmic and coordinated suck/swallow/breathe pattern
  • Oral-motor reflexes

(Arvedson & Brodsky 2002, p.305)

Formula Feeding

The formulas for premature infants specially formulated to provide 24 calories per ounce, compared with the 20 calories per ounce in standard formulas and human milk. By providing higher calorie content the formula allows the premature infant to receive the needed calories while ingesting less fluid ounces. The formulas designed for premature infants provide a protein mixture of 60% whey and 40% casein, this is similar to human milk. Traditional formula is 80% casein and 20% whey. (Arvedson & Brodsky, 2002, p. 262-265) This special formula is helpful forming smaller, softer curds in the infant’s stomach making it easier to digest.

A study published in the Archives of Disease in Childhood shows that premature infants fed human milk or special designed preterm formula display superior developmental scores at 18 months of age, when compared to those who are fed regular infant formula. (Lucus, Morley, Cole, & Gore, 1994) Formulas that are specifically designed for premature infants have been proven to promote growth and bone mineralization similar to intrauterine rates. (August, Teitelbaum, Albina, Bothe, Guenter, Heitkemper, Ireton-Jones, Mirtallo, Seidner, & Winkler, 2002)

NG OG tube feedings

Enteral feedings may begin once an infant’s digestive system is able to tolerate human milk or formula. These feeding may be provided through orogastric OG or nasogastric NG tubes until the infants is able to demonstrate their ability to receive nutrition orally. Small infants are primarily nose breathers, therefore OG tubes are preferred by many NICU professionals.

lily7(Photos of premature baby in NICU used with permission from the mother, Laura. (2006). www.lilyofmyheart.com)

Parenteral Nutrition

Parenteral nutrition (PN) is nutrition that is provided intravenously for infants that do not have a digestive system that is able to process nutrition. PN may be provided in the following ways:

  • Peripheral vein access
  • Central venous catheter (Broviac / Hickman catheter)
  • Central percutaneous intravascular catheter (PIC line)

lily6(Photos of premature baby in NICU used with permission from the mother, Laura. (2006). www.lilyofmyheart.com)


The breast milk produced by mother’s that give birth prematurely has been shown to have greater concentrations of many vitamins and minerals plus immune proteins, lipids, and fatty acids. (Edelstein & Sharlin, 2009) However the mother will only produce the preterm breast milk for 2-4 weeks after delivery and then her milk will be similar in composition to that produced by mother’s who gave birth at term. Because of the added nutritional and health benefits it is recommended that the preterm child receives this milk.

Breastfeeding may not be recommended for preterm infants weighing less than 1,250g, due to special dietary needs. (Arvedson & Brodsky, 2002, p. 262) Therefore the preterm breast milk may be pumped and stored until the infant is mature enough to receive it. The breast milk that is produced after the first 2-4 weeks may not have enough protein, sodium, phosphate, and calcium in it for the premature infant, therefore many medical professionals recommend fortifying the breast milk. (Edelstein & Sharlin, 2009) This has been shown to increase weight gain, length gains, and greater head circumference growth. (Edelstein & Sharlin, 2009)

Transition to Breast / Bottle Feedings

Non-nutritive Suck

For premature infants that are born before 32 weeks many are fed their mothers pumped milk or preterm formula by a feeding tube. Some have found it beneficial to encourage premature infants to engage in non-nutritive sucking (NSS), since this skill has been documented as being used by fetuses as early as 15 weeks gestational. A study by Pinelli and Symington showed that non-nutritive sucking reduced the length of a preterm infants hospital stay without posing any adverse affects if used correctly. (Pinelli & Symington, 1998). The NNS can be done by having the infant suck on a pacifier, finger, or the mother’s empty breast after she has pumped her milk. This method does not necessarily trigger a swallowing response, so it should not be the only factor used in determining an infant’s readiness for oral feedings. However, the sucking patterns used in NNS are organized bursts separated by pauses, which is a fundamental basis for nutritive sucking (NS). Furthermore the rhythmic motor sequences that are used in NNS are the same sequences needed during NS to express liquid from the nipple and create the suction necessary to draw the liquid toward the pharynx. (Miller & Kang, 2007)

(For further information, please see “Prematurity” section on the “Common Complications” page)

Stimulating Infant Sucking

Around 32 weeks gestation infants with stable respiration can tolerate brief period of stroking to help stimulate a sucking reflex. First the child is stroked on the cheeks and chin, gradually moving closer to the lips and mouth. Finally the caregiver strokes the tongue in a forward motion. The tongue is stoked at a rate of 1 stroke per second for 6-8 times. The finger is then left in the mouth to see if the child starts to suck. If not then the pattern is repeated for 5-10 minutes, unless the child shows signs of stress or fatigue, and the session is immediately stopped.


An infant is ready to transition to breastfeeding when they show signs of oral feeding readiness. During the feeding the infant needs to be placed in a flexed position and have jaw and cheek stability maintained. For infants that are ready for oral feedings, but need additional nourishment a supplemental nursing system can be used. A supplemental nursing system provides a regulated amount of additional breast milk or formula to the infant through a tube placed next to the nipple. The system can be phased out as the infant is able to receive more milk from the breast.

Bottle Feeding

Transitioning an infant to bottle feedings is similar to the transition to breast feedings in that you need to consider the readiness of the infant to feed orally and place them in a similar position. However, clinician’s can use a variety of different bottles, nipples, and viscosities to aid the infants in achieving a safe swallow. By selecting a nipple that allows the infant to form an adequate seal and has the appropriate fluid flow the infant is less likely to aspirate.

Feeding Child with Cleft Palate

Sucking for children with a cleft palate is difficult because of the poorly formed roof of the mouth.

  • Breastfeeding is allowed. Alternatives will need to be considered if adequate nutrition is not provided.
  • The infant should be held in an upright position to help keep the food from coming out of the nose.
  • Small, frequent feedings are recommended.
  • There are many types of bottles and nipples on the market that can assist with feeding an infant with cleft palate. The following are a few examples:
    • NUK nipple
      This nipple can be placed on regular bottles or on bottles with disposable bags. The hole can be made larger by making a criss-cross cut in the middle.
    • Mead Johnson Nurser®
      This is a soft, plastic bottle that is easy to squeeze and has a large crosscut nipple. You may use any nipple that the infant prefers with this system.
    • Haberman Feeder®
      This is a specially designed bottle system with a valve to help control the air the baby drinks and to prevent milk from going back into the bottle.
    • Syringes
      These may be used in hospitals following cleft surgery and may also be used at home. Typically, a soft, rubber tube is attached on the end of the syringe, which is then placed in the infant’s mouth.

(Children’s Hospital of Pittsburgh, 2008).

Water should be used to end feeding as it will facilitate cleaning of the cleft (Semmler & Hunter, 1990).  Efficient and safe feeding should be the goal when selecting feeding methods for infants with cleft lip and palate.  Supplemental feedings should be considered if feeding is not completed in 20 to 30 minutes as this may lead to loss of calories and energy (Glass & Wolf, 1999).


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