CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

Reference:

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PURPOSE
1. To provide guidelines for family, staff and physicians for the introduction and management of oral feeding for high-risk infants. 2. To create positive feeding experiences while assisting infants to achieve full oral feeding and to attempt to prevent the development of oral aversive behaviors.

UNDERLYING PRINCIPLES
1. 2. 3. 4. Feeding is an active social interaction between caregiver and infant. Development of oral feeding follows stages that can be identified.166,172 Stages are used to plan physiologically appropriate feeding experiences.172 Movement within and between stages may be bi-directional.

PRINCIPLES OF FEEDING ASSESSMENT

1. Continuous assessment of infant state and responses before, during and after non nutritive sucking (NNS) as well as nutritive sucking (NS), is essential. 146, 152, 154,166 2. Providing interventions that are contingent on infant responses is needed to achieve specific goals within each stage. 76, 152, 156 3. Reassessment of oral feeding process and plans should occur when: 3.1. Engagement/readiness cues are present and if positive signs persist: Identifiable hunger cues Increased/enhanced quiet alert state Stable physiologic responses 3.2. Disengagement/distress cues are present and if distress signs persist: Significant changes in heart rate (bradycardia, tachycardia) O2 saturation outside normal limits Color changes (pallor, cyanosis, mottled) Significant changes in respiratory status (rate, grunting, nasal flaring, retractions, apnea) Loss of postural tone Loss of state 3.3. Feeding skills improve: Improved suck/swallow/breathe (SSB) coordination Satiety cues

CHILD HEALTH

CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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POINTS OF EMPHASIS
1. Most premature infants will be able to feed by mouth without difficulty as they approach term gestation. 2. Gestational age and severity of illness may play a role in how long an individual infant remains in any one stage. 3. There is a wide range in ability at various gestational ages. For example a healthy preterm infant at 33 weeks adjusted age may be able to achieve total oral feedings while a 44 week adjusted age infant with chronic lung disease may not.

OVERVIEW OF THE ORAL FEEDING PRACTICE GUIDELINE: Non-oral stages Pre-oral Stimulation Stage Non-nutritive Sucking Stage Nutritive Sucking Stages Stage I: Minimal oral intake (<10% oral) Stage II: Moderate oral intake (10 to <80% oral) Stage III: Full oral intake (> 80% oral)

Page 3 Page 4 Page 5 Page 7 Page 10

Appendix I: Definitions Appendix II: Development of Premature Infant Feeding Behavior Appendix III: Parameters for Feeding Assessment

Page 11 Page 13 Page 15

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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STAGES OF NEONATAL FEEDING

Pre-Oral Stimulation Stage
GOALS Minimize negative oral stimulation8, 36,
52, 66, 76, 78

INFANT CHARACTERISTICS Responds adversely to handling Poor physiologic, motor & state regulation with or without stimulation 78, 127, 128, 129, 148 None to very weak oral reflexes (transient) 66 None to very weak non-nutritive skills 8, 36, 52, 66, 76, 78, 79 Not managing secretions (Neurological infants) 66

INTERVENTIONS Use developmental care interventions to facilitate midline position and flexion which promotes hand to mouth experience and behavioral organization 78,127,
128, 129

Promote behavioral organization Establish and maintain mothers milk supply 0 % oral intake

Skin-to-skin care (Kangaroo care) Positive experiences to the facial area as tolerated by infant. 33 Sustained touch Kisses by family Support the mother in initiating and maintaining lactation 11, 41 (See: Booklet: Breastfeeding Your Preterm Baby) Discuss with parents realistic expectations for initiation and progression of feeding 61, 185 Tube feeding only (Refer to Policy: 2-G-1 Gastric Tubes)

WHEN TO REFER Refer to LC when mother: Has difficulty establishing/ maintaining lactation Experiences complications as a result of pumping Has difficulty in accessing breast pump

Refer to OT when infant: Fails to progress or has extreme hypersensitivity to oral touching NB: first consider gestational age and severity of illness

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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Non-Nutritive Sucking Stage GOALS INFANT CHARACTERISTICS

Promote positive oral stimulation and NNS
66

INTERVENTIONS
Provide positive facial experiences and NNS: Infants fingers: position to support hand to mouth contact to allow the infant to suck when needed171 Pumped breast: allows infant to nuzzle and practice sucking. Skin-to-skin care (Kangaroo care) Soother/ pacifier: standard shaped nipples are recommended 18, 66, 171 (no orthodontic, flat or bulb shaped pacifiers); never force a nipple into the infants mouth Note: If baby has difficulty sucking and breathing, attempt to provide external pacing Transition to Pairing NNS and Tube Feeding:

WHEN TO REFER

Stable with handling and able to maintain physiologic, motor and state stability with NNS interventions148 Oral reflexes present or emerging Demonstrates licking and rooting By the end of this stage the infant will be able to demonstrate NNS by: Establishing and maintaining latch Rhythmical sucking bursts Coordinating sucking and breathing

Refer to LC when: There is a concern with mothers milk supply

Support the establishment and maintenance of mothers milk supply 0 % oral intake

Refer to OT: After first considering gestational age and severity of illness, refer to OT when infant: Is evasive or refusing NNS, or having difficulty coordinating sucking and breathing (e.g. chronic lung disease, neurological impairment) Fails to progress from this stage Refer to Home Nutrition Support Service, OT, and Neonatal Transition Team (NTT) or Pediatric Home Care when: Infant is to be discharged home on any amount of tube feeding

Consider placing a warmed drop of milk on the infants lip to promote the infant to bring their tongue forward to lick the milk Once infant demonstrates coordination of NNS (breathing and sucking), all above methods of NNS can be combined with tube feeding (e.g. gavage feeding while nuzzling at breast)

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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Nutritive Sucking Stage I: Minimal Oral Intake CRITICAL STAGE

GOALS
Oral practice only Quality and ambiance is more important than quantity taken 228 Experience is positive for infant and caregiver Infant is able to take small amounts of feeding orally in a controlled setting 8,
24, 28, 52, 66, 76

(<10% oral intake within a 24 hour period) WHEN TO REFER

Refer to LC when: Mothers milk supply is a concern Unable to achieve latch Infant is consistently frustrated at breast Complications present (e.g. cracked nipples, mastitis) Refer to OT when: (NB: first consider gestational age and severity of illness) Infant is at high risk for dysphagia (e.g. neurological impairment) 13; symptoms include: - Gurgling sounds in pharynx. - Coughing during feeding. - Congestion or noisy breathing during feeding - Good NNS but

INFANT CHARACTERISTICS
Infants who are breastfed may exhibit better O2 saturations than infants who are bottle fed. 40, 58, 168 Infants ~32 weeks adjusted age may begin to demonstrate readiness cues and be able to achieve this stage of nutritive sucking 100, 134, 164, 169, 170 Good NNS; emergent but no sustained SSB coordination Oral Intake < 10% daily volume Positive Readiness Cues: Manages secretions 24, 66 Maintains a quiet/alert state 25,
109,166

INTERVENTIONS
Minimize distracting stimuli 109,152 Aid infant to awake state a.c.
146, 148, 171

Skin-to-skin care (Kangaroo care) a.c.152. Intervene to prevent distress. Feedings should not be pushed 45, 78, 90,134,155 ,173 Therapeutic tasting drop milk onto soother from 1 ml syringe 1 drop at a time. External pacing to aid or prevent disorganized SSB 7, 27, 28, 97,121,147, 167 - Infants capable of limited self-pacing: gently roll infant forward (bottle in the mouth) until milk is out of nipple; allow infant to breath, reorganize, and cue for readiness - Infant not able to self-pace: Allow the infant to suck 3-4 times on the milk filled nipple, break suction, remove nipple from mouth. Allow infant to breath, reorganize, and cue for readiness. If infant does not open mouth spontaneously, elicit rooting reflex Note: Pauses need to be > length of sucking burst to allow adequate recovery

Emergent but not sustained coordination of SSB Beginning to self pace Licking/ Rooting/ Mouthing Resting RR <80 with no respiratory distress cues 24 Disengagement/ Distress Cues: Easily becomes physiological unstable Pooling of bolus Aspiration SSB becomes disorganized

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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Fatigues easily (falls asleep) Difficulty initiating feeding Head bobbing Loss of postural tone Loss of state

42, 44

Breastfeeding: Nuzzle at breast: encourages infant to root, smell, touch, lick, taste, or latch 31, If infant has difficulty with strong milk ejection reflex, try placing infant on a partially pumped breast 85 If infant behavior is disorganized at breast, try NNS (moms finger, infant fist, pacifier); once organized try placing back on breast Pair tube feeding with nuzzling at breast Refer to Pamphlet Breastfeeding Your Premature or Sick Infant

refuses NS Difficulty managing secretions (Aspiration may be silent)

Persistent feeding induced apnea and bradycardia Poor or unsustained latch i.e. an excessive wide jaw excursion Failure to progress from this stage

Bottle Feeding: Check for excessive milk flow: release pressure or change nipple before feeding Swaddle to promote organized behavior152 Provide postural stability147, e.g. side lying157 on pillow with head elevated Begin all feedings with 1-2 minutes NNS 32,64, 74, 89, 93 to help organize infant state and skills Place a drop of milk on the lip before feeding to help the infant organize for oral feeding Use low flow single-hole nipple 21, 40, 56, 80, 97,163,172 (losing liquid is OK to allow the infant to adjust volume). Do not allow the infant to become distressed. Do not jiggle or turn nipple to stimulate NS; this practice is contraindicated 152,173

Refer to Home Nutrition Support Service, OT and NTT or Pediatric Home Care when: Infant is to be discharged home on any amount of tube feeding

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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Nutritive Sucking Stage II: Moderate Oral Intake

GOALS
To ease the transition to full oral feeding by supporting endurance, skills and physiologic stability Quality and ambiance is still more important than quantity taken

(10% to <80% of oral feedings in a 24 hour period) INFANT CHARACTERISTICS INTERVENTIONS

Identifiable readiness cues: Hand to mouth, rooting Increased motor activity prior to feeding The infant may demonstrate readiness to feed at some feedings throughout the day, but not necessarily all the feedings166 Functional to good SSB 28, 31, 52, 66, 169 Improved endurance but not enough to maintain full oral feeding Immature state control unable to maintain quiet alert state throughout entire feeding 25 Consistent self- pacing may or may not be present A positive breastfeeding experience is defined as: an infant who demonstrates a good latch, sustained bursts of nutritive sucking, and audible swallowing for several minutes 41, 143 Aid infant to awake state a.c. 146, 173; NNS may help with state control and SSB coordination 148 Feedings should not be pushed. When a breastfeeding infant becomes more consistent with positive breastfeeding experiences, consider test weighing as this is the only accurate way to determine intake 11,12,19 Watch for distress/ disengagement cues closely and assess infants readiness to continue feeding; the infant should be alert, actively sucking, pacing, and coordinating their SSB; if infant does not demonstrate readiness to continue feeding or the infant demonstrates disengagement cues, remainder of feeding should be tube fed: 24, 52, 66, 76 Watch O2 10, 27, 87 and if the infant desaturates consider replacing with a #5 tube or removing the OG/NG tube for the feeding 63, 72 If tube in place, gavage remainder of feeding If tube not in place, make up the difference within a 24 hour period Consider concentrating milk to decrease volume required

WHEN TO REFER
Refer to LC when: Poor latch evident Infant falls asleep at breast Poor milk transfer suspected Considering test weighing Considering use of nipple shield 142

Refer to OT when: NB: first consider gestational age and severity of illness 38 Poor unsustained latch evident Flooding present Good NNS but poor NS Signs of dysphagia Persistent feeding induced apnea and Bradycardia Failure to progress from this stage

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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Infants who demonstrate an ability to take 30% of required volume and 1.5ml during the first 5 minutes of feeding may attain oral feeding earlier than others. 40 Note: Infants may develop physiological instability if pushed at this stage and require ongoing monitoring of saturation and heart rate

External and self- pacing may still be indicated, particularly in the first few sucks of a feeding, and if infant has chronic lung disease157. External Pacing for breastfed infants may be necessary for mothers with strong milk ejection reflex: Strategies include: Having mother pump breast a little before feeding
85

Refer to Home Nutrition Support Service, OT , and NTT or Pediatric Home Care when:

Removing baby from breast during milk ejection reflex Allowing baby to reorganize before placing back on breast Encourage breastfeeding mothers to spend long blocks of time in nursery to facilitate cue-base feeding 42, 41 Nutritive Sucking Stage II interventions may be further matched to the percentage oral intake as follows: Stage IIA: 10% to <25% oral vs tube Maximum 5-10 minute oral feeding time (breast or bottle) Oral practice only when cueing; likely 1-2 times/day Assess whether baby needs nonpumped or pumped breast for breastfeeding NNS &/or therapeutic tasting with tube feeds

Infant is to be discharged home on any amount of tube feeding

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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Stage IIB: 25% to <50% oral vs tube Typically >10 minute oral feeding time BF/B opportunities dependent on infant cues; aid to awake state ac Occasional full bottle taken Stage IIC: 50% to <80% oral vs tube Maximum 30 minute oral feeding time Offer BF/B opportunities every time infant cues May or may not need supplementation after BF/B; determine TFI range to allow flexibility in amount of tube feeding top up needed Assess need for indwelling vs intermittent NG/OG

CHILD HEALTH

CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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Nutritive Sucking Stage III: Full Oral Feeding (80% oral feedings in a 24 hour period)
GOALS INFANT CHARACTERISTICS INTERVENTIONS
Full oral feeding that supports growth Feeding experience is positive to infant and caregiver Sustains SSB throughout the feeding 24 , 28, 31, 66 Endurance to maintain nutritional intake to support growth Demonstrates clear hunger cues: Hand to mouth, rooting Increased motor activity Wakes to feed Demonstrates satiation cues: Slips off nipple at end of feeding Falls asleep at end of feeding

WHEN TO REFER
Refer to LC when: Poor latch evident Poor milk transfer suspected Poor weight gain Poor milk supply

Continue side lying and external pacing as required Transition to cue base feeding before discharge; intervals between feedings may vary greatly throughout day 11, 73, 112,118,136,147,149,150,152,156,160 If infant demonstrates disengagement cues, delay feeding until infant cues again Consider no top-up if infant consumes >80% of feed Consider oxygen saturation monitoring for 24 hours during all states including feeding (especially infants with chronic lung disease) 10,71 Encourage breastfeeding mothers to spend long blocks of time in nursery to facilitate cue-base feeding, and to room in for 48 hours before discharge 42, 41 Before discharge, the infant should be transitioned to the nipple and feeding regime that parents are planning to use at home.31,73 This will enable matching of the infants skills to the nipple to be used. A commercial single hole, straight nipple is recommended. If the infant does not tolerate this nipple, then the hospital supplied low flow nipple should be sent home 24, 52, 66 Ideally infant should spend >3 days in stage III pre-discharge

Most infants by 37-42 weeks adjusted age should be able to achieve Stage III of nutritive sucking 100, 134, 169

Refer to OT when: Infant discharged on total oral feeding but feeding skills are suspect 38: SSB incoordination Poor endurance Prolonged feedings > 45 minutes Neurological impairment

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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APPENDIX 1: DEFINITIONS
External Pacing (imposed breaks) 52, 66, 76, 126,145,161 - caregiver assists the infant in appropriately interspersing breaths during sucking bursts, to facilitate organization and rhythmicity; to decrease fatigue; and provide time for the infant to clear the bolus from the mouth or throat. This will support respiration by promoting deep breathing. Some infants require the nipple to be removed from the mouth because the nipple remaining in the mouth will continue to stimulate a sucking reflex 52. As a result, the infant will not swallow and take a breath, or will be sucking air on the empty nipple. External Pacing is done in 2 ways 52, 66, 126 If infant is capable of limited self-pacing (swallows and breathes during pauses): Gently and slowly roll infant forward with the bottle in the mouth until the milk is out of the nipple. Allow the infant to resume effective breathing, reorganize, and cue for readiness before rolling back to fill the nipple with milk again. If infant does not open mouth spontaneously, attempt to elicit rooting reflex. Verbalize infants cues for readiness to parents. If infant demonstrates no self-pacing: Then removal of the bottle for external pacing may be necessary. Allow the infant to suck 3-4 times on the milk filled nipple, then break suction and remove nipple from mouth and allow the infant to effectively breath, reorganize and cue for readiness. If infant does not open mouth spontaneously, attempt to elicit rooting reflex. Continue oral feeding only if infant demonstrates readiness cues. This allows the infant the choice to resume feeding. In this circumstance, the caregiver is pacing for the infant before distress cues are noted. Gastroesophageal Reflux (GER): a return or backward flow of gastric contents into the esophagus. Milk Ejection Reflex ( MER): another term for let down or the strong release of milk generally occurring at the beginning of a feeding which may also occur several times during the feeding. Non-nutritive sucking (NNS): 24, 66, 149, 171 repetitive sucking bursts and pauses in the absence of nutrient flow; numerous sucks (approx. 6 8) can be taken before a swallow, because the infant needs to accumulate a large enough secretion bolus before a swallow is triggered; a mature NNS rate is 2 sucks per second; the premature infant pattern usually begins with single sucks with long or irregular pauses; purpose is as a state regulatory mechanism and to satisfy sucking desire. Nutritive Sucking (NS): 24, 66 occurs during active sucking for the purpose of nourishment; this pattern is complex and significantly more challenging than non-nutritive sucking; twenty-six muscles and six cranial nerves must be coordinated for the pharyngeal swallow itself, to occur safely and efficiently; sucking pressure consists of compression and suction; mature rate is one

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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suck per second; Suck: Swallow Ratio is 1:1 but at the end of the feeding or with older infants may increase to 2:1(rate dependent on flow rate and size of oral cavity). Breastfeeding: - rate of sucking and suck: swallow ratio is variable and dependent on rate of milk flow Bottle feeding: - in the mature pattern, sucking bursts are longer at the beginning of the feeding and become shorter with longer pauses over the course of the feeding; the return of bubbles into the bottle is a reflection of the liquid flow; strength of suck is reflected in the resistance to removing the nipple and the rate of flow. Oral Feeding- nutritional intake by breastfeeding, cup feeding or bottle feeding. Suck/Swallow/Breathing Coordination (SSB): 24, 66, 76,164,169 Safe feeding requires precise coordination of processes that provide airway maintenance for breathing and airway protection during swallowing. Rhythmicity is the hallmark of normal feeding and is a reflection of smooth, split second coordination between sucking, swallowing and breathing. Immaturity or abnormality in any of these functions can have a profound effect on the other component and on the infants feeding ability. Assessment of SSB involves careful assessment of each of the components individually as well as the coordination and organization of all the components together Supplement Feeding: Feeding the infant via a mode other than the mothers chosen feeding goal-this may account for minimal amount of feed up to a complete feeding (100%). Tube Feeding: Nutritional intake by oral gastric, nasal gastric, nasal jejunal or gastrostomy tube.

CHILD HEALTH

CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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APPENDIX II. DEVELOPMENT OF PREMATURE INFANT FEEDING BEHAVIOR

Breastfeeding 31, 41, 143, 168 It is important to be aware of mothers milk supply as only non nutritive sucking will be observed if supply is very low; higher milk flow requires more mature sucking patterns. Sucking bursts are related to the flow of milk. Immature Mixed Mature Licking predominates Some rooting evident Obvious consistent rooting Little rooting evident Repeated short sucking Deep latch maintained bursts of ~ 6-15 sucks Shallow latch or Repeated long sucking difficulty maintaining bursts of ~ 15-30 sucks Swallowing beginning to latch be integrated into Swallow audible sucking burst Occasional short Pattern of bursts - suck sucking bursts of ~ 3- ~ 6-10 minutes of swallow breath or suck 5 sucks suck swallow breath nutritive sucking Pattern of burst is ~1 > 11 minutes of sucking 5 sucks pause and breath < 5 minutes of nutritive sucking Bottle Feeding 6, 47,50,75, 97, 100, 134, 151, 153, 159, 164 Immature

Mixed

Mature
Rhythmic alteration of suction and expression/compression Rate increases ~ 65/min Suck of consistently high amplitude Swallow consistently paired with suck > 90% of sucks organized into bursts Pauses more regular and short 10-40 sucks/burst

Predominantly expression/compression rather than suction usually ~ 2-3/second If suction is present it is of low amplitude Pattern is irregular or arrhythmic Expression/suction is not paired with swallow < 50% of expressions/sucks are organized into bursts <10 sucks per burst when burst present Breathing not consistently integrated into expression and swallow

Predominantly expression/compression Expression/compression pattern rhythmic usually ~ 1/second (55/min) Alteration of suction/expression emerging but arrhythmic Expression/suction inconsistently paired with swallow 50-90% of expressions/sucks organized into bursts Pauses irregular and generally long 10-20 sucks per burst

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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Immature Feeding Patterns That May Require Intervention: 24, 66

1. Prolonged Sucking (can lead to feeding induced apnea): Baby has lengthy sucking bursts without inter-dispersing breaths at appropriate intervals. The baby has difficulty with pacing SSB. Baby often has a strong, rapid suck but may have difficulty initiating breathing even after the nipple has been removed. The infant may terminate sucking to recover during the pause. If unable to terminate sucking independently, the infant becomes apneic with oxygen desaturation, cyanosis or bradycardia. 2. Short Sucking Bursts: Infant only takes 1-3 sucks before pausing to breathe. Pattern is rhythmic but pauses are frequent and long compared to the bursts. This pattern may result in decreased intake due to respiratory compromise and/or swallowing dysfunction. 3. Disorganized Sucking: Characterized by very disorganized and uneven sucking pattern. Duration of bursts and pauses vary considerably and there is an uncoordinated pattern of breathing and swallowing153, 165. Coughing and choking are frequent. Infants may be disorganized throughout the feeding or may begin organized and suddenly become disorganized. Causes: disorganized state and behavior, neurological deficit, respiratory problems158 or incompatible nipple flow rate.

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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APPENDIX III. PARAMETERS FOR FEEDING ASSESSMENT

1. Heart Rate 6, 24, 66,173 Tachycardia: If baseline heart rate is elevated or heart rate dramatically increases and remains elevated for prolonged time. This indicates work of feeding may be excessive. Increases in 10 bpm during feeding are not uncommon. Larger increases may indicate that demands of feeding are excessive. However if an infant has a high baseline heart rate, even small increases in heart rate can indicate great physiologic stress. Bradycardia: A drop in heart rate below 90 or 100 BPM. When observed with feeding, bradycardia is a significant and possibly life threatening event. Common causes include: - Poor positioning during feeding - Aspiration, structural anomalies, vagally mediated laryngospasm - Prolonged sucking pattern and stretch receptors (sensory receptors) in pharynx stimulated by large bolus - Presence of nasogastric tubes (touch-pressure receptors) or - Micro aspiration of food or by reflux (chemoreceptors) 2. Respiratory Status 24, 52, 66, 173 Respiratory rate should be evaluated at the beginning, mid and post-feeding and time required to return to baseline should be measured. Respiratory rate is individual and depends on the infants ability to compensate for the reduction in ventilation imposed by feeding. Increase RR leads to increase risk of incoordination of SSB and increase risk of aspiration. For infants with respiratory compromise, a resting RR (when awake), <65 to 70 breaths per minute is a conservative guideline for initiating feeding. Respiratory rates>80 breaths/min. during pauses and prolonged recovery to baseline, indicate that work of breathing is too great and non-oral feeding is recommended until respiratory work during feeding is reduced. Signs of respiratory distress: Tachypnea = >60 breaths per min. Nasal flaring/blanching, Retractions Chin tugging, Shallow catch breaths. Neck extension/arching O2 desaturation

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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3. Oxygen Saturation Term and preterm infants experience slight but measurable oxygen desaturation with bottle feeding (dips with continuous sucking & return to baseline during intermittent sucking). However for compromised infants with borderline saturations, theses reductions can be significant. Sudden dips may be associated with apneic or bradycardic episodes, whereas a gradual decline may indicate inadequate respiratory support for feeding. Desaturation may be an isolated event and seen with out significant observable change e.g. no change in color. During breastfeeding, oxygen saturation levels usually remain higher and exhibit less fluctuation than during bottle feeding. 40, 70,162 Refer to Guideline: 2-P-3 Pulse Oximetry in Neonates. 4. Clinical Indications of Swallowing Dysfunction (risk for aspiration) 66 Choking during swallowing Inability to handle own oral secretions Noisy, wet upper airway sounds after individual swallows or increasing noisiness over course of feeding Multiple Swallows to clear single bolus Apnea during swallowing History of frequent upper-respiratory infections or pneumonias 5. Aspiration can result from a primary swallowing dysfunction or from incoordination between sucking, swallowing, and breathing. Aspiration can be descending (during feeding) or ascending (during gastroesophageal reflux). 24 Sometimes aspiration occurs with fatigue towards the middle or end of a feeding and is referred to fatigue aspiration. 66, 126 Aspiration can be silent (no coughing present). It can only be confirmed with a videofluoroscopic swallow study (VFSS). 24,
126

10, 24, 70, 66, 87, 131, 134, 173

6. Videofluoroscopic Swallowing Study (VFSS) is a radiographic study that evaluates the status and safety of the pharyngeal swallow. Barium is used to image pharyngeal structures and function. During the study, treatment techniques (altering the texture, temperature, and bolus size) are attempted to determine if swallowing can be improved. 66, 173

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES

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ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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CROSS REFERENCES
MANUAL: 1. Booklet: Breastfeeding Your Preterm Baby 2. Book: From Here Through Maternity 3. Child Health Policy 2-G-1 SUBJECT/TITLE: On units On units Gastric Tubes: Neonates

REFERENCES
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18. Nowak, A. J., Smith, W. L., & Erenberg, A. (1994). Imaging evaluation of artificial nipples during bottle feeding. Arch Pediatr Adolesc Med, 148, 40-42. 19. Meier, P., Lysakowski, T. Y., Engstrom, J. L., Kavanaugh, K. L., & Mangurten, H. H. (1990). The accuracy of test weighing for preterm infants. Journal of pediatric gastroenterology & nutrition, 10(1), 62-65. 20. Lang, S., Lawrence, C. J., & Orme, R. L. (1994). Cup feeding: an alternative method of infant feeding. Archives of Disease in Childhood, 71(4), 365-369. 21. Mathew, O. P. (1990). Determinants of milk flow through nipple units. Role of hole size and nipple thickness. American Journal of Diseases of Children, 144(2), 222-224. 22. Neifert, M., Lawrence, R., & Seacat, J. (1995). Nipple confusion: towards a formal definition. The Journal of Pediatrics, 126(6), S125-S129. 23. Holloway, E. (1994). Parent and occupational therapist collaboration in the neonatal intensive care unit. The American Journal of Occupational Therapy, 48(6), 535-538. 24. Glass, R. P., & Wolf, L. S. (1994). A global perspective on feeding assessment in the neonatal intensive care unit. The American Journal of Occupational Therapy, 48(6), 514-526. 25. McCain, G. (1997). Behavioral state activity during nipple feedings for preterm infants. Neonatal Network, 16(5), 43-44. 26. Kliethermes, P. A., Cross, M. L., Lanese, M. G., Johnson, K. M., & Simon, S. D. (1999). Transitioning preterm infants with nasogastric tube supplementation: Increased likelihood of breastfeeding. JOGNN, 28(3), 264-273. 27. Blaymore Bier, J., Ferguson, A., Cho, C., Oh, W., & Vohr, B. R. (1993). The oral motor development of low-birthweight infants who underwent orotracheal intubation during the neonatal period. American Journal of Diseases of Children, 147, 858-862. 28. Meyer-Palmer, M. (1993). Identification and management of the transitional suck pattern in premature infants. Journal of Perinatal & Neonatal Nursing, 7(1), 66-75. 29. Engebreson, J. C., & Wind-Wardell, D. (1997). Development of a pacifier for low-birth-weight-infants' nonnutritive sucking. JOGNN, 26(6), 660-664. 30. Blondheim, O., Abbasi, S., Fox, W. W., & Bhutani, V. K. (1993). Effect of enteral gavage feeding rate on pulmonary functions of very low birth weight infants. The Journal of Pediatrics, 122(5), 751-755. 31. Meier, P., & Anderson, G. C. (1987). Responses of small preterm infants to bottle-and breastfeeding. MCN, 12, 97-105. 32. Pickler, R. H., Higgins, K. E., & Grummette, B. D. (1993). The effect of nonnutritive sucking on bottle-feeding stress in preterm infants. JOGNN, 22(3), 230-234. 33. Gaebler, C. P., & Redditi Hanzlik, J. (1996). The effects of a pre-feeding stimulation program on preterm infants. American Journal of Occupational Health, 50(3), 184-192. 34. Meyer-Palmer, M., Crawley, K., & Blanco, I. A. (1993). Neonatal oral-motor assessment scale: A reliability study. Journal of Perinatology, 13(1), 28-35. 35. Braum, M. A., & Meyer-Palmer, M. (1985). A pilot study of oral-motor dysfunction in at-risk infants. Physical and Occupational Therapy in Pediatrics, 5(4), 13-25. 36. Meyer-Palmer, M., & Heyman, M. B. (1993). Assessment and treatment of sensory-versus motor-based feeding problems in very young children. Infant and Young Children, 6(2), 67-73. 37. Bu'Lock, F., Woolridge, M. W., & Baum, J. D. (1990). Development of co-ordination of sucking, swallowing, and breathing: Ultrasound study of term and preterm infants. Developmental Medicine and Child Neurology, 32, 669678. 38. Hawdon, J.M., Beauregard, N., Slattery, J., & Kennedy, G. (2000). Identification of neonates at risk of developing feeding problems in infancy. Developmental Medicine & Child Neurology, 42, 235-239. 39. Matthews, C. L. (1994). Supporting suck-swallow-breath coordination during nipple feeding. American Journal of Occupational Health, 48(6), 561-562. 40. Blaymore Bier, J., Ferguson, A., Andersen, L., Soloman, E., Voltas, C., Oh, W., & Vohr, B. R. (1993). Breastfeeding of very low birth weight infants. The Journal of Pediatrics, 123(5), 773-778. 41. Nyqvist, K. H., Rubertsson, C., Ewald, U., & Sjoden, P. (1996). Development of the preterm breastfeeding behavior scale (PIBBS): A study of nurse-mother agreement. Journal of Human Lactation, 12(3), 207-215.

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42. Meier, P., Engstrom, J. L., Mangurten, H. H., Estrada, E., Zimmerman, B., & Kopparthi, R. (1993). Breastfeeding support services in the neonatal intensive-care unit. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 22(4), 338-347. 43. Bell, E. H., Geyer, J., & Jones, L. (1995). A structured intervention improves breastfeeding success for ill or preterm infants. MCN, 20, 309-314. 44. Meier, P., & Brown, L. P. (1996). State of science: Breastfeeding for mothers and low birth weight infants. Nursing Clinics of North America, 31(2), 351-365. 45. Lemons, P. K., & Lemons, J. A. (1996). Transition to breast/bottle feedings: the premature infant. Journal of the American College of Nutrition, 15(2), 126-135. 46. Poets, C. F., Langner, M. U., & Bohnhorst, B. (1997). Effects of bottle feeding and two different methods of gavage feeding on oxygenation and breathing patterns in preterm infants. Acta Paediatrica, 86, 419-423. 47. Lau, C., Sheena, H. R., Shulman, R. J., & Schanler, R. J. (1997). Oral feeding in low birth weight infants. The Journal of Pediatrics, 130(4), 561-569. 48. Nyqvist, K. H., Sjoden, P. O., & Ewald, U. (1994). Mothers' advice about facilitating breastfeeding in a neonatal intensive care unit. Journal of Human Lactation, 10(4), 237-243. 49. Gonzales, I., Duryea, E. J., Vasquez, E., & Geraghty, N. (1995). Effect of enteral feeding temperature on feeding tolerance in preterm infants. Neonatal Network, 14(3), 39-43. 1A. 50. Conway, A. (1994). Instruments in neonatal research: Measuring preterm infant feeding ability, Part 1: Bottle feeding. Neonatal Network, 13(4), 71-74. 51. Wood, A. F. (1991). Factors affecting reciprocity between nurses and preterm infants during feeding. Journal of Perinatal & Neonatal Nursing, 4(4), 62-70. 52. Shaker, C. S. (1999). Nipple feeding preterm infants: An individualized, developmentally supportive approach. Neonatal Network, 18(3), 15-22. 53. Pridham, K. F., Sondel, S., Chang, A., & Green, C. (1993). Nipple feeding for preterm infants with bronchopullmonary dyplasia. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 22(2), 147-155. 54. Pickler, R. H., Frankel, H. B., Walsh, K. M., & Thompson, N. M. (1996). Effects of nonnutritive sucking on behavioral organization and feeding performance in preterm infants. Nursing Research, 45(3), 132-135. 55. Howard, C. R., deBlieck, E. A., tenHoopen, C. B., Howard, F. M., Lanphear, B. P., & Lawrence, R. A. (1999). Physiologic stability of newborns during cup- and bottle feeding. Pediatrics, 104(5), 1204-1207. 56. Mathew, O. P. (1988). Nipple units for newborn infants: A functional comparison. Pediatrics, 81(5), 688-691. 57. Daniels, H., Devlieger, H., Casaer, P., Ramaekers, V., Van Den Broeck, J., & Eggermont, E. (1988). Feeding, behavioral state and cardiorespiratory control. Acta Paediatrica Scand, 77, 369-373. 58. Meier, P. (1988). Bottle-and breastfeeding effects on transcutaneous oxygen pressure and temperature in preterm infants. Nursing Research, 37(1), 36-41. 59. Pickler, R. H., Mauck, A. G., & Geldmaker, B. (1997). Bottle-feeding histories of preterm infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 26(4), 414-420. 60. Baker, B. J., & Rasmussen, T. W. (1997). Organizing and documenting lactation support of NICU families. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 26(5), 515-521. 61. Anderson, G. C., Behnke, M., Gill, N. E., & Conlon, M. (1990). Self-regulatory gavage to bottle feeding for preterm infants: Effects on behavioral state, energy expenditure, and weight gain. In S. G. Funk, E. M. Tornquist, M. T. Champagne, L. A. Copp, & R. A. Wiese (Eds.), Key Aspects of recovery: Improving Nutrition, Rest, and mobility. (pp. 83-97). New York: Springer. 62. Ymington, A., Ballantyne, M., Pinelli, J., & Stevens, B. (1995). Indwelling versus intermittent feeding tubes in premature neonates. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24(4), 321-326. 63. Shiao, S. P. (1997). Comparison of continuous versus intermittent sucking in very-low-birth-weight infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 26(3), 313-319. 64. DiPietro, J. A., Cusson, R.M., OBrien Caught, M., & Fox, N.A. (1994). Behavioral and physiologic effects of nonnutritive sucking during gavage feeding in preterm infants. Pediatric Research, 36(2), 207-214. 65. Azyk, S. (1990). Factors associated with the transition to oral feeding in infants fed by nasogastric tubes. The American Journal of Occupational Therapy, 44(12), 1070-1078.

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66. Wolf, L. S., & Glass, R. P. (1992). Feeding and Swallowing Disorders in Infancy: Assessment and Management. Therapy Skill Builders. 67. Hill, P. D., Hanson, K. S., & Mefford, A. L. (1994). Mothers of low birthweight infants: breastfeeding patterns and problems. Journal of Human Lactation, 10(3), 169-176. 68. Gill, N. E., Behnke, M., Conlon, M., & Anderson, G. C. (1992). Nonnutritive sucking modulates behavioral state for preterm infants before feeding. Scandinavian Journal of Caring Science, 6(1), 3-7. 69. Hill, A. S. (1992). Preliminary findings: A maximum oral feeding time for premature infants, the relationship to physiological indicators. Maternal-Dhild Nursing Journal, 20(2), 81-92. 70. Cagan, J. (1995). Feeding readiness behavior in preterm infants. Neonatal Network, 14(2), 82 71. Shiao, S. P., Brooker, J., & DiFiore, T. (1996). Desaturation events during oral feedings with and without a nasogastric tube in very low birth weight infants. Heart & Lung, 25(3), 236-245. 72. Pridham, K. F., Brown, R., Sondel, S., Green, C., Wedel, N. Y., & Lai, H. (1998). Transition Time to Full Nipple Feeding for Premature Infants With a History of Lung Disease. JOGNN, 27(5), 533-545. 73. Saunders, R. B., Friedman, C. B., & Stramoski, P. R. (1991). Feeding Preterm Infants. Schedule or Demand? JOGNN, 20(3), 212-218. 74. McCain, G. C. (1995). Promotion of Preterm Infant Nipple Feeding With Nonnutritive Sucking. Journal of Pediatric Nursing, 10(1), 3-8. 75. Hanlon, M. B., Tripp, J. H., Ellis, R. E., Flack, F. C., Selley, W. G., & Shoesmith, H. J. (1997). Deglutition apnoea as indicator of maturation of suckle feeding in bottle-fed preterm infants. Developmental Medicine & Child Neurology, 39, 534-542. 76. Comrie, J. D., & Helm, J. M. (1997). Common Feeding Problems in the Intensive Care Nursery: Maturation, Organization, Evaluation, and Management Strategies. Seminars in Speech and Language, 18(3), 239-261. 77. Mattes, R. D., Maone, T., Wagner-Page, S., Beauchamp, G., Bernbaum, J., Stallings, V., Pereira, G. R., Gibson, E., Russell, P., & Bhutani, V. (1996). Effects of sweet taste stimulation on growth and sucking in preterm infants. JOGNN, 25(5), 407-414. 78. Ancona, J., Shaker, C. S., Puhek, J., & Garland, J. S. (1998). Improving Outcomes Through a Developmental Approach to Nipple Feeding. Performance Improvement, Ideas & Innovations, 220-223. 79. Meyer-Palmer, M. (1998). Weaning from Gastrostomy Tube Feeding: Commentary on Oral Aversion. Pediatric Nursing, 23(5) 80. Mathew, O. P. (1991). Breathing patterns of preterm infants during bottle feeding: Role of milk flow. The Journal of Pediatrics, 119(6), 960-965. 81. Lehtonen, J., Kononen, M., Purhonen, M., Partanen, J., Saarikoski, S., & Launiala, K. (1998). The effect of nursing on the brain activity of the newborn. The Journal of Pediatrics, 132(4), 646-651. 82. Schrank, W., Al-Sayed, L. E., Beahm, P. H., & Thach, B. T. (1998). Feeding responses to free-flow formula in term and preterm infants. The Journal of Pediatrics, 132(3 Part 1), 426-430. 83. Case-Smith, J., Cooper, P., & Scala, V. (1989). Feeding Efficiency of Premature Neonates. The American Journal of Occupational Therapy, 43(4), 245-250. 84. Lemons. P.K. (2001). From gavage to oral feedings: just a matter of time. Neonatal Network, 20(3), 7-14. 85. Narayanan, I. (1990). Sucking on the emptied breast a better method of non-nutritive sucking than use of a pacifier. Indian Pediatrics, 27, 1122-3. 86. Kimble, C. (1992). Nonnutritive sucking: Adaptation and Health for the Neonates. Neonatal Network, 11(2), 2933. 87. Medoff-Cooper, B. (1991). Changes in Nutritive Sucking Patterns with Increasing Gestational Age. Nursing Research, 40(4), 245-247. 88. Miller, H. D., & Anderson, G. C. (1993). Nonnutritive Sucking: Effects on Crying and Heart Rate in Intubated Infants Requiring Assisted Mechanical Ventilation. Nursing Research, 42(5), 305-307. 89. Gill, N. E., Behnke, M., Conlon, M., McNeely, J., & Anderson, G. (1988). Effect of nonnutritive sucking on behavioural state in preterm infants before sucking. Nursing Research, 37(6), 347-350. 90. Meyer-Palmer, M., & VandenBerg, K. A. (1998). A closer look at neonatal sucking. Neonatal Network, 17(2), 7778.

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91. Case-Smith, J. (1988). An efficacy study of occupational therapy with high-risk neonates. American Journal of Occupational Therapy, 42(8), 499-506. 92. Goldson, E. (1987). Nonnutritive sucking in the sick infant. Journal of Perinatology, 7(1), 30-34. 93. Geggie, J. H., Dressler-Mund, D. L., Creighton, D., & Cormack-Wong, E. R. (1999). An interdisciplinary feeding team approach for preterm, high-risk infants and children. Canadian Journal of Dietetic Practice and Research, 60(2), 72-77. 94. Siddell, E. P., & Froman, R. D. (1994). A national survey of neonatal intensive care units: Criterial used to determine readiness for oral feedings. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 23(9), 783-789. 95. Kennedy, C., & Lipsett, L. P. (1993). Temporal characteristics of non-oral feedings and chronic feeding problems in premature infants. Journal of Perinatal & Neonatal Nursing, 7(3), 77-89. 96. Freer, Y. (1999). A comparison of breast and cup feeding in perterm infants: Effects of physiologic parameters. Journal of Neonatal Nursing , 5(1), 16-21. 97. Lau, C., & Schanler, R. J. (2000). Oral feeding in premature infants: advantages of a self-paced milk flow. Acta Paediatrica, 89, 453-459. 98. Premji, S.S., & Paes, B. (2000). Gastrointestinal function and growth in premature infants: Is non-nutritive sucking vital? Journal of Perinatology, 1, 46-53. 99. Ramsay, M., & Gisel, E.G. (1996). Neonatal sucking and maternal feeding practices. Developmental Medicine and Child Neurology. 38, 34-47. 100. Lau, C., Alagugurusamy, R., Schanler, R.J., Smith, E.O., & Shulman, R.J. (2000). Characterization of the developmental stages of sucking 8n preterm infants during bottle feeding. Acta Paediatrica, 89, 846-854. 101. MacMullan, N.J., & Dulski. L.A. (2000). Factors related to sucking ability in healthy newborn. JOGNN, 29(4), 390-396. 102. Kuehl, J. (1997). Cup feeding the newborn: what you should know. The Journal of Perinatal and Neonatal Nursing , 56-60. 103. Hall, W.A., Shearer, K., & Kavanagh, R. (1996). Comparison of confidence between mothers who breastfed and formula fed their preterm infants. The Journal of Perinatal and Neonatal Nursing, 44-55. 104. Frakaloss, G., Burke, G., & Sanders, M.R. (1998). Impact of gastroesophageal reflex on growth and hospital stay in premature infants. Journal of Pediatric Gastroenterology and Nutrition, 26, 146-150. 105. Kelleher, K.J., Casey, P.H., Bradley, R.H., Pope, S.K., Whiteside, L., Barrett, K.W., Swanson, M.E., & Kirby, R.S. (1993). Risk factors and outcomes for failure to thrive in the low birth weight preterm infants. Pediatrics, 91(5), 941-948. 106. Rogers, B., Andrus, J., Msall, M., Aredson, J., Sim, J., Ross, T., Martin, D., & Hudak, M.(1998). Growth of preterm infants with cystic periventricular leukomalacia. Developmental Medicine and Child Neurology, 40, 580586. 107. Sauve, R.S., & Geggie, J.H. (1992). Feeding problems in continuing care of preterm infants. The Canadian Journal of Pediatrics, April, 49-54. 108. Medcoff-Cooper, B. (2000). Multi-system approach to the assessment of successful feeding. Acta Paediatrica, 89, 393-398. 109. Medoff-Cooper, B., McGrath, J.M., & Bilker, W. (2000). Nutritive sucking and neurobehavioral development in preterm infants from 34 weeks PCA to term. MCN, 25(2), 64-70. 110. Hill, A.S., Kurkowski, T.B., & Garcia, J. (2000). Oral support measures used in feeding the preterm infant. Nursing Research, 49(1), 2-10. 111. Dowling, D. (1999). Physiological responses of preterm infant to breastfeeding and bottle-feeding with the orthodontic nipple. Nursing Research, 48(2), 78-85. 112. Pridham, K., Kosorok, M.R., Greer, F., Carey, P., Kayata, S., & Sondel, S. (1999). The effects of prescribed versus ad libitum feedings and formula caloric density on premature infant dietary intake and weight gain. Nursing Research, 48(2), 86-93. 113. Timms, B.J., DiFiore, J.M., Martin, R.J., & Miller, M.J. (1993). Increased respiratory drive as an inhibitor of oral feeding of preterm infants. The Journal of Pediatrics, 123(1), 127-131. 114. Adams Weaver, K., & Anderson, G.C. (1988). Relationship between integrated sucking pressures and first bottle-feeding scores in premature infants. JOGNN, 17(2), 113-120.

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115. Morris, B.H., Miller-Loncar, C.L., Landry, S.H., Smith, K.E., Swank, P.R., & Denson, S.E. (1999). Feeding, medical factors, and developmental outcome in premature infants. Clinical Pediatrics, 38(8), 451-456 116. Pinelli, J., & Symington, A. (2000). Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. The Cochrane Library, 3. 117. Conde-Agudelo, A., Diaz-Rossello, J.L>, & Belizan, J.M. (2000). Kangaroo mother care to reduce morbidity and mortality in low birth weight infants. The Cochrane Library, 1. 118. McCain, G.C., Gartside, P.S., Greenberg, J.M., & Lott, J.W. (2001). A feeding protocol for healthy preterm infants that shortens time to oral feeding. The Journal of Pediatrics 139(3), 374-9. 119. Meyer, E.C., Garcia Coll, C.T., Lester, B.M., Boukydis, C.F., McDonough, S.M., & Oh, W. (1994). Family-based intervention improves maternal psychological well being and feeding interaction of preterm infants. Pediatrics, 93(2), 241-246. 120. Olivet, L.W., Law Harrison, L., Sherrod, R.A., Jeon, J. (1990). The feeding as an outcome measure in teaching parents of preterms. NCAST National News, 6(4), 1-3. 121. Singer, L.T., Davillier, M., Preuss, L., Szekely, L., Hawkins, S., Yamashita, T., & Baley, J. (1996). Feeding interactions in infants with very low birth weight and bronchopulmonary dysplasia. Developmental and Behavioral Pediatrics, 17(2), 69-76. 122. Lobo, M.L. (1992). Parent-infant interaction during feeding when the infant has congenital heart disease. Journal of Pediatric Nursing, 7(2), 97-105. 123. Farel, A.M., Reeman, V.A., Keenan, N.L., & Huber, C.J. (1991). Interaction between high-risk infants and their mothers: the NICAST as an assessment tool. Research in Nursing and Health, 14, 109-118. 124. Rochat, P., Goubet, N., & Shah, B.L. (1997). Enhanced sucking engagement by preterm infants during intermittent gavage feedings. Developmental and Behavioral Pediatrics, 18(1), 22-26. 125. Daley, H.K., & Kennedy, C.M. (2000). Meta analysis: effects of interventions on premature infants feeding. Journal of Perinatal and Neonatal Nursing, 14(3), 62-77. 126. Evans Morris, S. & Dunnklein, M. (2000). Pre-feeding Skills. Second Edition. Therapy Skill Builders. 127. Als, H., Lawhon, G., Duffy, F., McAnulty, G., Gibes-Grossman, R., & Blickman, J. (1994). Individualized developmental care for the very low-birth-weight preterm infant. JAMA, 272(11), 853-9858. 128. Becker, P., Gruneald, P., Moorman, J., & Stuhr, S. (1991). Outcomes of developmentally supportive nursing care for very low birth weight infants. Nursing Research, 40(3), 150-155. 129. Buehler, D.M., Als, H., Duffy, F., McAnulty, G., & Liederman, J. (1995). Effectiveness of individualized developmental care for low-risk preterm infants: Behavioral and electrophysiologic evidence. Pediatrics, 96(5), 923-932. 130. Thorye, S. M. (2001). Challenges mothers identify in bottle-feeding their preterm infants. Neonatal Network, 20(1), 41-50. 131. Craig, C.M., Lee, D.M., Freer, Y.N., and Laing, I.A. (1999). Modulations in breathing patterns during intermittent feeding in term infants and preterm infants with brochopulmonary dysplasia. Developmental Medicine and Child Neurology, 41(9), 616-24. 132. Hill, A.S. & Rath, L. (1999). The relationship between drooling, age sucking pattern characteristics and physiologic parameters of preterm infants during bottle-feeding. Research for Nursing Practice, 1(2), 8 pages (http://www.graduatereasearch.com/hill.htm). 133. Wheeler, J., Chapman, C., Johnson, M., & Langdon, R. (2000). Feeding outcomes and influences within the neonatal unit. International Journal of Nursing Practice, 6(4), 196-206. 134. Gewolb, I.H., Vice, F.L., Schweitzer-Kenney, E.L., Taciak, V.L., & Bosma, J.F (2001). Developmental patterns of rhythmic suck and swallow in preterm infants. Developmental Medicine and Child Neurology, 43(1), 22-7. 135. Gewolb, I.H., Bosma, J.F, Taciak, V.L, & Vice, F.L. (2001). Abnormal developmental patterns of suck and swallow rhythms during feeding in preterm infants with bronchopulmonary dysplasia. Developmental Medicine and Child Neurology, 43(), 454-9. 136. Waber, B., Hubler, E.G. & Paddon, M.L. (1998). A comparison of outcomes in demand versus scheduled formula fed premature infants. Nutrition in Clinical Practice, 13(3), 132-5. 137. Cagan, J.B.Z. (1993). Feeding readiness behavior in preterm infants. Doctoral Dissertation, Rush University College of Nursing, Illinois.

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138. Shiao, S.P.K, Chang, Y., Lannon, H., & Yarandi, H. (1997). Meta-analysis of the effects of nonnutritive sucking on heart rate and peripheral oxygenation: research from the past 30 years. Issues in Comprehensive Pediatric Nursing, 20, 11-24. 139. Dowling, D.A., Meier, P.P., DiFiore, J.M., Blatz, M.A. & Martin, R.J. (2002). Cup-feeding for preterm infants: mechanics and safety. Journal of Human Lactation, 18(1), 13-20. 140. Malhotra, N., Vishwambaran, L., Sundaram, K.R., & Narayanan, I. (1999). A controlled trial of alternative methods of oral feeding in neonates. Early Human Development, 54(1), 29-38. 141. Martin, M., and Shaw, N.J. (1997). Feeding problems in infants and young children with chronic lung disease. Journal of Human Nutrition and Dietetics, 10 (5), 271-275. 142. Meier, P.P., Brown, L.P., Hurst, N.M., Spatz, D.L., Engstrom, J.L., Borucki, L.C., & Krouse, A.M. (2000). Nipple Shields for preterm infants: Effect on milk transfer and duration of breastfeeding. Journal of Human Lactation, 16(2), 106-114. 143. Nyqvist K.H.., Sjoden P., Ewald U. (1999). The development of preterm infants' breastfeeding behavior. Early Human Development, 55: 247-264. 144. Brazelton TB.(1984). Neonatal Behavioral Assessment Scale 2nd edition. Philadelphia: J.B. Lippincott Co. 145. Als H. Manual for Naturalistic Observation of Newborn Behavior: Preterm and Full term Infants. (1984). Boston MA: The Children's Hospital. 146. McGrath, J.M & Medoff-Cooper, B. (2003). Alertness and feeding competence in extremely early born preterm infants. Newborn and infant nursing reviews, 9(3), p. 174-186. 147. Ludwig, S.M. (2007). Oral feeding and the late preterm infant. Newborn & infant nursing reviews, 7(2), p. 72-75. 148. Pickler, R.H. (2005). A model of feeding readiness for preterm infants. Neonatal intensive care, 18(4), p. 17-22. 149. Pridham, K.F., Kosorok, M.R., Greer, F., Kayata, S., Bhattacharya, A. & Grunwald, P. (2001). Comparison of caloric intake and weight outcomes of an ad lib feeding regime for preterm infants in two nurseries. Journal of advanced nursing, 35(5), 751-759. 150. Pridham, K.F., Schroeder, M., Brown, R. & Clark, R. (2001). The relationship of a mothers working model of feeding to her feeding behaviour. Journal of advanced nursing, 35(5), 741-750. 151. Medoff-Cooper, B., McGrath, J.M. & Shults, J. (2002). Feeding patterns of full-term and preterm infants at forty weeks postconceptual age. Journal of developmental and behavioral pediatrics, 23, 231-236. 152. McGrath, J.M. & Braescu, A.V.B. (2004). State of the science: Feeding readiness in the preterm infant. Journal of Perinatal & Neonatal Nursing, 18(4), 353-368. 153. Lau, C., Smith, E.O. & Schanler, R.J. (2003). Coordination of suck-swallow and swallow respirationg in preterm infants. Acta Pediatrica, 92, 721-727. 154. Howe, T., Sheu, C., Hinojosa, J., Lin, J. & Holzman, I.R. (2007). Multiple factors related to bottle-feeding performance in preterm infants. Nursing Research, 56(5), 307-311. 155. Thoyre, S.M. (2007). Feeding outcomes of extremely premature infants after neonatal care. JOGNN, 36, 366376. 156. Kirk, A.T., Alder, S.C. & King, J.D. (2007), Cue-based oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants. Journal of Perinatology, 27, 572-578. 157. Clark, L., Kennedy, G., Pring, T. & Hird, M. (2007). Improving bottle feeding in preterm infants: Investigating the elevated side-lying position. Infant, 3(4), 154-158. 158. Gewolb, I.H. & Vice, F.L. (2006). Abnormalities in the coordination of respiration and swallow in preterm infants with bronchopulmonary dysplagia. Developmental Medicine & Child Neurology, 48, 595-599. 159. Gewolb, I.H. & Vice, F.L. (2006). Maturational changes in the rhythms, patterning, and coordination of respiration and swallow during feeding in preterm and term infants. Developmental Medicine & Child Neurology, 48, 589594. 160. Crosson, D.D. & Pickler, R.H. (2004). An integrated review of the literature on demand feedings for preterm infants. Advances in Neonatal Care, 4(4), 216-225. 161. Law-Morstatt, L., Judd, D.M., Snyder, P., Baier, R.J. & Dhanireddy, R. (2003). Pacing as a treatment technique for transitional sucking patterns. Journal of Perinatology, 23(6), 483-488.

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162. Goldfield, E.C., Richarson, M.J., Lee, K.G. & Bargetts, S. (2006). Coordination of sucking, swallowing, and breathing and oxygen saturation during early infant breast-feeding and bottle-feeding. Pediatric Research, 60(4), 450-455. 163. Chang, Y., Lin, C. Lin, Y & Lin, C. (2007). Effects of single-hole and cross-cut nipple units on feeding efficiency and physiological parameters in premature infants. Journal of Nursing Research, 15( 3), 215-222. 164. Amaizu, N., Shulman, R.J., Schanler, R.J. & Lau, C. Maturation of oral feeding skills in preterm infants. Acta Paediatrica, 97, 61-67. 165. Da Costa, S. & van der Schans, C. (2008). The reliability of the neonatal oral-motor assessment scale. Acta Paediatrica, 9, 21-26. 166. White-Traut, R., Berbaum, M., Lessen, B., McFarlin, B., & Cardenas, L. (2005). Feeding readiness in preterm infants. Maternal Child Health Nursing, 30(1), 52-60. 167. Medhoff-Cooper, B. (2005). Nutritive sucking research from clinical questions to research answers. Journal of Perinatal & Neonatal Nursing, 19(3), 265-272. 168. Chen, C., Wang, T., Chang, H. & Chi, C. (2000). The effect of breast-and bottle-feeding on oxygen saturation and body temperature in preterm infants. Journal of Human Lactation, 16(21), 21-21. 169. Mizuno, K. & Ueda, A. (2003). The maturation and coordination of sucking, swallowing, and respiration in preterm infants. The Journal of Pediatrics, Jan., 36-40. 170. Bromiker, R., Arad, I., Loughran, B. Netzer, D., Kaplan, M. & Medhoff-Cooper, B. (2005). Comparison of sucking patterns at introduction of oral feeding and at term in israeli and American born preterm infants. Acta Paediatrica, 94, 201-204. 171. Boiron, M., Nobrega, L., Roux, S., Henrot, A. & Saliba, E. (2007). Effects of oral stimulation and oral support on non-nutritive sucking and feeding performance in preterm infants. Developmental Medicine & Child Neurology, 49, 439-444. 172. Burklow, K., McGrath, A. & Kaul, A. (2002). Management and prevention of feeding problems in young children with prematurity and very low birthweight. Infants & Young Children, 14(4), 19-30. 173. Ross, E & Browne, J. (2002). Developmental progression of feeding skills: an approach to supporting feeding in preterm infants. Seminars in Neonatology, 7, 469-475. 174. Canadian Asthma Report. Levels of Evidence. From: www.cmaj.ca/cgi/reprint/161/11suppl1/s1. Accessed 1999.

ACKNOWLEDGEMENT
We wish to thank the following staff for their dedication and contribution to the Regional Neonatal Oral Feeding Protocol:
Joanna Chan Jo Chang Donna Dressler-Mund Tanis Fenton Darlene Goodwin Sharon Harvey Heather Howarth Maureen Jobson Lucy Kim Linda Kostecky Ruth Kovacs Karen Lasby Toni MacDonald Laurie McCormack Debbie McNeil Carolyn Miron Cathy Orton Shahirose Premji Jennifer Reed Pattie Schumacher Jeanne Scotland Edie Scott Tammy Sherrow Ann Smith Marilynne Steward Carol Turko April von Platen

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES

Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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DISCLAIMER
All content in this policy and/or procedure is copyright, Calgary Health Region. All rights reserved. This information, and as amended from time to time, was created expressly for use by Calgary Health Region staff and persons acting on behalf of the Calgary Health Region for guiding actions and decisions taken on behalf of the Calgary Health Region. The Calgary Health Region accepts no responsibility for any modification and/or redistribution and is not liable in any way for any actions taken by individuals based on the information herein, or for any inaccuracies, errors, or omissions in the information in this policy and/or procedure. Any modification and/or adoption of this policy and/or procedure are done so at the risk of the adopting organization.

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