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Feeding in the NICU and Issues That Influence Success

Erin Sundseth Ross
Department of Pediatrics, Section of Nutrition, School of Medicine, University of
Colorado
Denver, CO

Abstract
Premature infants are both medically fragile and immature; both of these factors
influence their ability to safely feed. Speech-language pathologists (SLPs) working
with these infants must recognize normal development of feeding skills as well as
diagnose feeding problems and develop individualized treatment plans.
Assessments should include all three phases of swallowing (oral, pharyngeal,
and esophageal) in the context of overall stability, and interventions need to be
individualized to the unique needs of each infant. Decreasing the flow rate of fluid
and providing pacing are frequently used strategies to support the medically
fragile infant. Therapeutic programs that do not appreciate the role of both
individual developmental progression and medical comorbidities are not
appropriate, given that volume is not the only goal of feeding. Rather, SLPs must
focus on skill acquisition for long-term success within the larger context of
parental nurturing. Medical comorbidities significantly influence both the initiation
and the progression of oral feeding in this population. The individual variation in
development, as well as the medical fragility in this population, challenges the
neonatal intensive care unit (NICU) therapist to appreciate the complexity of
feeding and to work in collaboration with the other members of the team.

Introduction
The speech-language pathologist (SLP) in a neonatal intensive care unit (NICU)
will spend a considerable amount of time supporting infants in the area of feeding. To
do so, the therapist must understand normal feeding development and identify infants
whose feeding behaviors are atypical. Therapeutic interventions must be individualized
to the infant’s specific developmental stage and medical condition, because
comorbidities directly influence the transition to and success in oral feeding. NICU-
based SLPs face unique challenges in supporting feeding for this population.
Feeding is a complex activity that is influenced by both physiologic stability and
maturation. The term infant is born with a mature physiologic system and quickly
transitions to oral feeding; the premature infant often lacks the stability and skill to
coordinate sucking, swallowing, and breathing. While there is an expectation that
feeding occurs prior to term, the gestational age (GA) when feeding matures is
influenced by both individual variation and medical comorbidities. Therapeutic
interventions that do not consider the individuality of the infant or the interaction
between the infant and the caregiver lack a holistic understanding of the complexity of

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 feeding. Feeding is seen as a unique opportunity for nurturing that is not
accomplished through any other caregiving task and one that influences parents’
views of competence in parenting (Pridham, Lin, & Brown, 2001). The goal of the SLP
should be to provide assessments and interventions that maintain stability during the
feeding, in collaboration with the infant, the family, and the other members of the
NICU team.
Physiologic stability is the foundation of oral feeding. Feeding disrupts
respiration; therefore, respiratory effort must be considered during oral feeding
(Porges, 1996). Infants with lung disease or other physiologic comorbidities (e.g.,
digestive) are at highest risk for long-term feeding disorders (Rommel, De Meyer,
Feenstra, & Veereman-Wauters, 2003). Motor stability underlies successful feeding as
well, and oral-motor skills develop in an organized, observable progression for the
healthy preterm infant, but are negatively influenced by medical comorbidities.
Feeding also requires the ability to alert, maintain stability in other areas, and focus
on feeding. In Als’ Synactive Theory, these systems communicate and a disruption in
one system negatively affects stability in the other systems (Als, 1982). The Synactive
Theory has been integrated as a foundation for feeding models (Pickler, 2004). The
NICU therapist must strive for infant stability before, during and after any interaction.
SLPs in the NICU may provide developmental support for the preterm infant
during feeding development and provide individualized interventions for infants who
have feeding difficulties (Fletcher & Ash, 2005; Shaker & Woida, 2007). There are
several frameworks that assist the therapist in providing developmental feeding
support for the preterm infant. One such framework is the Baby Regulated
Organization of Systems and Sucking (BROSS; Ross & Browne, 2003). The BROSS is
an eight-step progression that uses stability across physiologic, motor, and arousal
(state) systems as well as observable feeding behaviors to monitor progression towards
competent feeding. The NICU therapist can use the BROSS framework along with
individualized assessments to guide decisions regarding initiation and progression in
feeding. The healthy, preterm infant will progress up the BROSS steps, from stability
in the bed to organized feeding. The SLP can also identify those infants who are not
progressing as expected and develop therapeutic interventions to support movement
up the steps. Therapists need to consider the progression within the context of both
individual variation and medical comorbidities that directly influence the time it takes
to transition to oral feedings (Frakaloss, Burke, & Sanders, 1998; Mandich, Ritchie, &
Mullett, 1996). Research consistently indicates the mean GA to transition to full oral
feedings is 36 to 37 weeks, despite the use of therapeutic interventions designed to
speed the process in preterm infants (Amaizu, Shulman, Schanler, & Lau, 2008;
Fucile, Gisel, & Lau, 2005; Medoff-Cooper, 2005). Preterm infants should not be
considered delayed simply because they lack a mature suck, swallow, and breathe
pattern. Much like age-correcting for other developmental milestones, the ability to
orally feed should be considered within the context of development. Preterm infants do
typically demonstrate an observable, predictable progression leading to a fully
integrated, mature feeding pattern. Therefore, SLPs should identify and assess infants
who are not following this normal progression. The oral phase of feeding can be
evaluated with non-nutritive sucking (NNS) and all three phases of feeding (oral,
pharyngeal and esophageal) with nutritive sucking (NS; Darrow & Harley, 1998).

Evaluation of Feeding Skills

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 Bedside evaluations should begin with an assessment of stability during NNS.
The therapist can evaluate rooting and latching, as well as the integration (or lack
thereof) of suction and compression during NNS. If compression is present without
suction, the pacifier will fall out of the mouth as the infant compresses the nipple. In
contrast, the pacifier will remain firmly in the mouth and the infant will resist
attempts at removal if both components are integrated. Infants who lack suction when
given the pacifier may be immature or may have a structural defect (e.g., cleft palate).
An immature infant may demonstrate compression-only sucking because suction lags
behind compression in development (Lau, Alagugurusamy, Schanler, Smith, &
Shulman, 2000). If the infant is developmentally immature, opportunities for NNS
positively affect both behavioral state and physiologic organization and will promote
physiologic stability (Pinelli & Symington, 2005). However, if the infant is older and all
other systems appear to be stable and mature, the therapist should rule out a
structural defect and/or consider using a compression bottle system if poor suction
and compression are observed. These special bottle systems facilitate flow and
compensate for the lack of suction, but may interfere with the integration of suction in
the immature infant (Chang, Y. J., Lin, C. P., Lin, Y. J., & Lin, C. H., 2007). Pending
stability during the oral phase of feeding, nutritive sucking with the added
requirements of pharyngeal and esophageal phases should be evaluated.
Infants must coordinate sucking, swallowing, and breathing (SSB) to safely feed
during NS, which is more complex than NNS. The rate, strength, and coordination of
the SSB sequence should be evaluated by offering the infant a standard bottle nipple
unless there is reason to choose a slower or faster flowing nipple. If the therapist is
concerned about the infant’s ability to tolerate volume, a taste of formula or breast
milk may be offered, using either a pacifier dipped in fluid or a pacifier system/bottle
system designed to severely limit flow rate. The assessment should focus on the ability
to express fluid, while integrating swallowing and breathing and maintaining stability.
A number of assessment schema are available to the therapist to evaluate feeding,
although the psychometric properties of formal assessments are weak (da Costa, van
den Engel-Hoek, & Bos, 2008; Howe, Lin, Fu, Su, & Hsieh, 2008). The therapist
should be able to recognize infant signs of instability while feeding, and volume of fluid
should be only one part of an assessment.
As noted above, the NS assessment examines both the oral and pharyngeal
phases of feeding. Poor abilities in either phase may result in (a) inefficient feeding, (b)
loss of fluid, (c) poor coordination of swallowing and breathing, or (d) choking. The
therapist must assess the etiology for any of these and understand the role of flow rate
in each phase. Fluid loss, limited jaw and tongue excursions, and the use of
compression-only sucking may be compensatory strategies purposefully engaged by
the infant to decrease flow rate during NS and to safely manage fluid in both the oral
and pharyngeal phases (Eishima, 1991). Inappropriately increasing flow rate in the
medically fragile infant may disrupt the development of suction and result in a loss in
overall feeding skills and volume. Alternatively, the infant with a poor oral phase of
feeding may benefit from increased flow rate. Flow rate is an important variable to
consider during both the assessment and the development of interventions.
Some infants continue to have difficulty with NS despite alterations in flow rate
and may benefit from further instrumental swallow evaluation (e.g., modified barium
swallow study). However, the evaluation must be conducted within the context of
normal development. Currently data are lacking to guide when it might be appropriate

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 Porges, S. (1996). Physiological regulation in high-risk infants: A model for assessment and potential intervention. Development
and Psychopathology, 8, 43-58.
Pridham, K., Lin, C. Y., & Brown, R. (2001). Mothers' evaluation of their caregiving for premature and full-term infants through
the first year: contributing factors. Research in Nursing and Health, 24(3), 157-169.
Rommel, N., De Meyer, A. M., Feenstra, L., & Veereman-Wauters, G. (2003). The complexity of feeding problems in 700
infants and young children presenting to a tertiary care institution. Journal of Pediatric Gastroenterology and Nutrition, 37(1),
75-84.
Ross, E. S., & Browne, J. V. (2003, January). The baby regulated organization of systems and sucking. Abstract presented at The
Physical and Developmental Environment of the High-Risk Infant Conference, Clearwater Beach, FL.
Shaker, C. S., & Woida, A. M. (2007). An evidence-based approach to nipple feeding in a level III NICU: Nurse autonomy,
developmental care, and teamwork. Neonatal Network, 26(2), 77-83.

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 respiratory break, thereby proactively avoiding feeding-induced apnea. Pacing with
preterm infants results in fewer episodes of physiologic instability and increased
efficiency in oral-motor patterns at discharge (Law-Morstatt, Judd, Snyder, Baier, &
Dhanireddy, 2003). Both a slower flow rate and external pacing should be considered
when working with the medically fragile infant.
For the infant who is not able to maintain stability and/or a safe swallow
despite altered flow rate and pacing, a therapist will often consider thickening feedings
based upon the swallow assessment. Thickening of feedings to facilitate safe swallows
in preterm infants is not without controversy, due to concerns regarding how the
immature gut tolerates thickening agents such as rice cereal or commercial thickening
agents (Patole, 2007). Thickening of feedings should be considered for the mature
infant who is unable to achieve a safe swallow after other therapeutic interventions
have been exhausted.

Influence of Medical Comorbidities

While prematurity is a significant risk factor for feeding difficulties, infants with
respiratory and digestive problems are most at-risk for long-term feeding problems
(Field, Garland, & Williams, 2003; Rommel et al., 2003). Both of these organ systems
support physiologic stability, and, without this underlying stability, the infant’s
experience of feeding may be aversive and may lead to long-term feeding issues.
Respiratory difficulties can alter both the progression towards full oral feedings and
the oral-motor feeding pattern itself, because they negatively influence the ability to
coordinate SSB (Gewolb & Vice, 2006). Infants with either respiratory or cardiac
conditions often become hypoxic (with and without apnea), and are frequently fatigued
and irritable. Decreasing flow rate and volume, while increasing caloric density and/or
frequency of nipple feeds, may be appropriate interventions for the infant with
respiratory and/or cardiac comorbidities, as is close collaboration with a pediatric
nutrition specialist (Gewolb & Vice). Another medical comorbidity that influences the
time to transition to oral feedings is gastroesophageal reflux (GER; Frakaloss et al.,
1998), one of the most common comorbidities for infants referred to feeding clinics
(Rommel et al.). Thickening of feedings for the treatment of gastroesophageal reflux in
preterm infants is also controversial (Corvaglia et al., 2006; Patole, 2007), but is often
recommended for the term infant who has uncomplicated reflux (Chang, Lasserson,
Gaffney, Connor, & Garske, 2006). Smaller volumes and more frequent feeds may also
be appropriate (Poets, 2004).

Summary
Preterm infants are both medically fragile and immature. This combination
influences the timing and progression of oral feeding development. Infants with
comorbidities are especially vulnerable to disruptions in the progression of oral skill
development. Preterm infants are not delayed term infants; rather, preterm infants
may be developmentally normal in the context of their gestational age. The goal of the
SLP in the NICU is to facilitate oral feeding by supporting stability as well as a normal
developmental progression, while devising individualized therapeutic interventions for
those infants who are not acquiring normal feeding skills. Slowing the flow rate and
pacing the feeding are two common strategies used in the NICU. Therapists should
reserve faster flowing and compression-only bottle systems and oral-motor supports
for those infants who are able to maintain physiologic stability while tolerating

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 increased flow. Long-term success depends on a foundation of physiologic stability
and skill acquisition, rather than on volume alone.

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 Porges, S. (1996). Physiological regulation in high-risk infants: A model for assessment and potential intervention. Development
and Psychopathology, 8, 43-58.
Pridham, K., Lin, C. Y., & Brown, R. (2001). Mothers' evaluation of their caregiving for premature and full-term infants through
the first year: contributing factors. Research in Nursing and Health, 24(3), 157-169.
Rommel, N., De Meyer, A. M., Feenstra, L., & Veereman-Wauters, G. (2003). The complexity of feeding problems in 700
infants and young children presenting to a tertiary care institution. Journal of Pediatric Gastroenterology and Nutrition, 37(1),
75-84.
Ross, E. S., & Browne, J. V. (2003, January). The baby regulated organization of systems and sucking. Abstract presented at The
Physical and Developmental Environment of the High-Risk Infant Conference, Clearwater Beach, FL.
Shaker, C. S., & Woida, A. M. (2007). An evidence-based approach to nipple feeding in a level III NICU: Nurse autonomy,
developmental care, and teamwork. Neonatal Network, 26(2), 77-83.

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