Less is More : The Key to a Positive
Feeding Experience
Maureen Luther, B.Sc (P.T) MA
Paediatric Physiotherapist
1.Discuss the implementation of developmentally
supportive feeding interventions within the NICU
2.Evaluate the theoretical framework that guides cue
based feeding and use this framework to maximize
feeding potential of the preterm infant
3.Discuss the long term ramifications of negative feeding
experiences and the interventions utilized by the
Neonatal Follow-up clinic
Goals of Developmentally
Supportive Care in the NICU
NICU intervention Strategies for the infant focuses on
stress reduction (Als, H, 1982)
• Evidence is accumulating that stress during early human
ontogeny is also associated with long-term modifications
of neurobehavioural development
• Sensitivity of the young nervous system to stress-related
factors implies that reduction of stress is an important
goal of early intervention before term age. (Hadders-Algra,2011)
Neurodevelopmental processes during human ontogeny
(De Graaf-Peters & Hadders-Algra, Early Hum Dev 2006; 82: 257-66
Goals of Developmentally
Supportive Care in the NICU
• Facilitate responsive parenting
“ sensitive to their infants cues and have the
ability and knowledge to alleviate infant’s
stress” ( NCAST, 1994)
• Foster positive parent- child relationship
-attachment fostered by the mother/infant dyad learning about each
-disrupted for preterm infants
“Vulnerable to forming lower-quality attachment to caregiver due
to disruption of early experiences and separation” ( Sullivan et al,
Goals of Developmentally
Supportive “Feeding” Care
• Oral feeding
- interactive, developmental task (Thoyre and Brown, 2004)
- the most complex and highly co-ordinated
sensorimotor mode of oral feeding
- requires appropriate oral motor development and
function with neurological maturation
- is dependent on the mother / child interaction
- feeding needs to be a pleasant, relaxed and a
controlled experience
Understanding Oral Motor Development
for Successful Feeding
Somatesthetic (Tactile) Development
First sense to develop:
8weeks – the perioral area
10 weeks - palms of hands,
plantar surface of feet
11 weeks - entire face
Sensation of pressure, pain, and
Protective mechanism
Provides information through which
neurodevelopment and cognition is
Understanding Oral Motor Development
for Successful Feeding
• Taste cells: form at 7-8 weeks GA, functionally mature
by 17 weeks
• Fetal swallowing – begins at 12 weeks GA
• Rhythmical bursts of jaw opening and closing - 14
weeks GA
• Non Nutritive Sucking – 18 weeks GA
• Safe, effective Swallow -32 weeks GA
• Coordinated sucking and swallowing – by 35 to 40
(Lipchock et al, 2012, Brown,J & Ross, E, 2011)
Medical issues affecting feeding
• Hypotonia - related to GA, BW, Severity of illness
• Respiratory:Bronchopulmonary Dysplasia (BPD):
contributes to poor SSB coordination
significant increases in deglutition apnea
poor sucking endurance and performance
( Gewolb,IR & Vice, FL 2006, Mizuno,K et al, 2007)
• Neurological
Dysfunctional suck– may exclude breastfeeding
(NOMAS, Palmer,M 1992)
NICU: Positive Feeding Strategies
• Developmentally supportive environment during the
feeding process:
-appropriate lighting
-sound levels within the unit
• Primary Nursing Care:
- essential to consistency and relationship building
- cluster of non-emergent care
NICU: Positive Feeding Strategies
• Positioning : a positive oral experience
- Flexion – sucking is a flexion activity
- Midline – hands to mouth
- Promoting comfort and sleep
Non Nutritive Sucking:
-provides comfort and self-soothing
( Pinelli and Symington, 2010)
NICU: Positive Feeding Strategies
• Stressful procedures: Are we providing support and comfort?
• Opportunities for a positive oral experience
Procedures: Diaper change , vital signs
Bolus feeds
“ Tube fed infants increase NNS when exposed to smell of Expressed
Breast Milk which suggests this may assist in transition to oral
feeding” (Lipchock SV et al , 2011)
NICU: Positive Feeding Strategies
Pain Management :
• Negative oral experiences: are they painful?
- Taping
- Suctioning
- Placement of OG/NG tubes
- Intubations
• Use of pharmacological and non-pharmacological
pain management strategies
NICU: Positive Feeding Strategies
• Skin to Skin Care
• Infant Benefits:
– Improved physiological stability
– More organized sleep wake cycles (Ludington Hoe,S 2006)
– Decreased nosocomial infections
– Non-pharmacological pain management strategy (AAP,
2006, Johnston,C et al, 2003, 2008)
• Parent Benefits:
– Improved breastfeeding duration and milk production
– Improved attachment
– Increased confidence (Johnson, AN. 2007)
“Kangaroo care is crucial
for babies to grow and
develop and is also
medicine for the souls of
quote from parent during our Kangaroo-a-thon
NICU: Positive Feeding Strategies
• Cue-based feeding – Quality versus Quantity?
- a positive feeding experience for the infant
- a developmental process that requires support from
moment to moment ( Shaker, CS 2012)
• Need to move away from the viewpoint that a successful
feed is based on numbers
( Ross,E & Philbin,K 2011)
NICU: Positive Feeding Strategies
• A successful Cue-Based Feeding involves:
• Infant
- physiologically stable
- actively participating
- self regulated
- comfortable
• Caregiver
- sensitive to infants cues – state and physiologic
- responds appropriately to cues
- competent feeding skills (Ross,E & Philbin K, 2011)
NICU: Positive Feeding Strategies:
Understanding the Infant’s Cues
Stress Cues:
Vital Signs: RR, HR, O2 sat
Respiratory: increased WOB
Visceral: gagging, vomiting
State : rapid state change
Sensory: facial/ gaze aversion
Oral Motor: uncoordinated SSB
Motor: head turning, extension,
increased limb movement
NICU: Positive Feeding Strategies:
Understanding the Infant’s Cues
Stability Cues
• Vital Signs: stable RR 40-60
• Respiratory: pause = burst
• State regulation
• Oral Motor: rooting,
coordinated SSB
• Motor: gentle forward
Hunger and satiation cues
NICU: Positive Feeding Strategies:
Understanding the Infant’s Cues
Consequences of not responding to stress cues:
Compromise physiological stability
Loss of state regulation and postural control
Possible Laryngeal penetration/ aspiration
Eventually Feeding Refusal Behaviour/ Feeding
Altered Brain Development
Altered parent/infant attachment
NICU: Positive Feeding Strategies
Feeding Readiness:
• Begins with physiologic stability
“ stable vital signs, good colour, and good muscle tone
when the infant is alone in the bed or during simple
handling “( Ross,E & Philbin,K, 2011)
• Infant begins to show signs of hunger
• Infant can maintain physiologic stability and a drowsy or
alert state while being held with NNS ( Ross,E & Philbin,K, 2011)
Feeding Readiness® Scale
(Ludwig and Waitzman 2007)
If scores 1 or 2 – can attempt to orally feed
If scores 3-5 – do not attempt to orally feed
1) Alert or fussy prior to care. Rooting and/or hands to mouth
behavior. Good tone.
2) Alert once handled. Some rooting or takes pacifier. Adequate tone.
3) Briefly alert with care. No hunger behaviors (i.e. rooting, sucking).
Adequate tone.
4) Sleeping throughout care. No hunger cues. No change in tone.
5) Significant HR, RR , 02, or WOB outside of baseline HR <100 bpm,
RR > 60 bpm , SaO2 <80 % WOB=nasal flaring, tracheal tugging
Action: Stop feeding, reassess, if scores 1-2 and physiologically
returns to baseline, retry once more
NICU: Positive Feeding Strategies
• Physiologically easier
“infants with BPD who were breastfed were found to
have higher O2 saturations during feeding than bottle
feeding” ( Mizuno et al, 2007)
• Baby active participant, mother is supportive
NICU: Positive Feeding Strategies
Bottle feeding
• An appropriate feeding alternative
-can be physically easier
-with cue based feeding the feeder needs to be
carefully watching the infant and taking his lead
-infant is a co-regulatory partner in the feeding
process (Shaker,C 2013)
NICU: Positive Feeding Strategies
Bottle feeding
• Goals:
• Safety: prevent aspiration, physiologic instability,
excessive fatigue
• Functional : adequate volumes for growth without undue
stress to infant
• Relationship based – nurturing – infant and parent –
should be pleasant for both
• Individual and developmentally supportive
(Ludwig and Waitzman, 2007)
NICU: Positive Feeding Strategies:
Responding to cues
• Feeding continues if infant maintains strong coordinated
• Allow for opportunities for “catch up” breathing
NICU: Positive Feeding Strategies:
Responding to cues
• Respond to disengagement/stress cues
“Feeding is stopped when infant communicates that he is done or
the inability to continue for whatever reason NOT just when the
bottle is empty/volume driven” ( Shaker,CS 2013)
• Intake is a byproduct of a quality feeding interaction and
within the context of the emerging feeding skills
NICU: Positive Feeding Strategies:
Providing individualized support
External pacing:
a method of providing external control of the infant’s
SSB ( Palmer,M 1993,Philbin&Ross, 2011)
-Assists infant’s physiologic stability
-Prevents the formation of maladaptive, oromotor
-Increases infant’s comfort with feeding
-Assists an appropriate intake volume
NICU: Positive Feeding Strategies:
Providing individualized support
External Pacing:
Need to be anticipatory and preventative
start with horizontal bottle
count the Sucks and Swallows ( allow 3-5)
if followed by breathe, allow pause
if no breathe, tip bottle down, keep nipple in mouth
Signs to pace – raising eyebrows*, nasal flaring, eyes
widening, pulling back ( Ludwig, SM & Waitzman, KA 2007)
NICU: Positive Feeding Strategies:
Providing individualized support
Postural Control:
supportive swaddling with a blanket ( Wolf L & Glass,R 1992)
“hand swaddling ” control with hands ( Philbin &Ross, 2011)
by grasping hand – promotes flexion
NICU: Positive Feeding Strategies:
Providing individualized support
- good alignment for best function
- promoting attachment
enface “the position in which the caregiver’s face is
rotated so that the eyes and those of the child’s can
meet fully in the same vertical plane of rotation” (NCAST,
No difference in semi reclined vs upright vs elevated
side lying positioning in improving oral feeding skills
( Lau,C 2013)
NICU: Positive Feeding Strategies:
Providing individualized support
• Appropriate Nipple selection:
• Consistency of liquid:
to thicken or not?
• Therapeutic techniques: When are they really
Jaw support
Jaw and cheek support
NICU: Positive Feeding Strategies
Feeding Plan:
-consistency is critical
-communication of the plan
-need to reduce variation – interferes with learning to
- plan needs to be developed by the various members of
the team including the parent
NICU: Positive Feeding Strategies
Fostering parent /child relationship
• Start early to include parents in the care of their infants
• Modeling
• Coaching
• Anticipatory Guidance
NICU: Positive Feeding Strategies
Fostering parent /child relationship
Goals of the NICU caregiver:
-Facilitate the parent/ child relationship by promoting a
co-regulated feeding approach
- Foster confident and competent parents
NICU: Positive Feeding Strategies
Fostering parent /child relationship
Understanding the stressors for the parents:
Inconsistent information
Excluded from the feeding plan and changes in the
Respecting the parents choice – breast or bottle
Not watching the baby’s cues
Feeding should be a joyful experience
Feeding – “this is the worst” – when baby not feeding
Parent really feels like a bad parent
NICU: Positive Feeding Strategies
Preparing for Discharge
Successful and safe feeding often delays discharge
( Shaker, CS, 2012, Lau C, 2003)
• Parent - confident and competent
• Infant:
medically stable
a safe feeding plan
supports growth and nutrition
promotes positive parental interaction
NICU: Positive Feeding Strategies
Avoiding Feeding difficulties/problems
• Absence of early ( normal) postnatal chemosensory
experiences , disruption in maternal attachment and
negative associations with early feeding experiences
contribute to future feeding difficulties (Lipchock, SV et al, 2011)
• Strong association between feeding and discomfort
( including struggling to breathe and reflux) can develop
an aversion to feeding (Philbin & Ross, 2011)
• Most infants who develop feeding problems are averse
to food and feeding (Ross,E and Philbin,K 2011)
Neonatal Follow-up: Early Intervention
Feeding issues in the first year
• Higher incidence of early regulatory disorders
( excessive crying, sleeping difficulties and/or feeding
problems) in preterm infant (Arpi E, Ferrari F. 2013)
• Crying, feeding and sleeping problems has a correlation
with poor cognitive outcome and behavioural problems
(Wolke,2009 )
• Regulatory problems in infancy can increase the
likelihood of developing behavioral problems in
childhood (Hemmi MH et al, 2011)
• By school age, ELBW children have a greater risk to
have eating problems ( Samara M et al, 2009)
Neonatal Follow-up: Early Intervention
• First 6 months: Feeding
De – medicalize feeding
• Feeding : 3 pronged approach
– Growth & nutrition
– Age appropriate oral motor
skill, positioning and assist
in transitions
– Positive Maternal /child
feeding interaction
( Arvedson, J. 2002 )
• Address GERD - criteria for
intervention and management
Neonatal Follow-up: Early Intervention
• 6-12 months: Feeding to
• Expanding texture acquisition
• Decreasing fluid intake
• New utensils
• Proper seating
• Mealtime rules and routines
( Chatoor et al, 1997 and DeGangi, G,
• Self-feeding
• Social activity
Conclusion: Less is More
• Emphasis on quantity of feed
• Stress during feeding
• Skin to Skin
• Emphasis on quality of feed
• Cue based feeding
• Parental input

Less is more: the key to a positive feeding experience