The New Insight Feeding Skills and Management Feeding Problem in the Preterm Infant

Suck is a relatively mature ororhythmic motor behavior in a full-term infant and is integral to competent oral feeds. However, preterm infants often demonstrate oromotor discoordination and are unable to suck and feed orally. This inability represents a serious challenge to both the neonatal intensive care unit (NICU) “graduates” and the physician-provider-parent teams.

Birth weight is an important determinant of future nutritional status and growth patterns in infancy. Low birth weight has been associated with future undernutrition and growth faltering. An important mediator of the association between birth weight and infant growth may be feeding maturation. Infant feeding involves integrative coordination of sucking, swallowing and breathing, and impaired nutritive feeding may be an indicator of neurobehavioural dysfunction.

In at-term infants, nutritive sucking frequency and maximal negative sucking pressure increase, and time between successive bursts and sucks decreases with increasing post-conceptual age. However, there is limited data on feeding skill development in preterm infants and potential contributing factors . Gestational age is associated with feeding maturation in preterm infants, but birth weight may be an important biological condition that may influence infant cognitive and motor development  that has not been sufficiently examined. Birth weight and gestational age may each have a separate influence on infant neurodevelopment . Additionally, extremely early born preterm infants demonstrate increased morbidity and mortality as birth weight decreases, independent of gestational age. No known study has examined the association between premature infants’ feeding maturation and birth weight. Understanding developmental changes in feeding behaviour and the association between feeding maturation and birth weight could lead to interventions to improve the postnatal care of preterm infants in order to optimize future health and promote adequate growth.

Feeding competency is a frequent and serious challenge to the neonatal intensive care unit survivors and to the physician-provider-parent teams.  The urgency of effective assessment and intervention techniques is obviated to promote safe swallow, as attainment of oral feeding for the preterm infant/newborn is one of the prerequisites for hospital discharge. If left unresolved, feeding problems may persist into early childhood and may require management by pediatric gastroenterologists and feeding therapists. The motor control and development of nonnutritive and nutritive suck, swallow, and coordination with respiration in preterm populations. Medolf reported that ignificant neurobehavioral maturation takes place between 40 and 44 weeks PCA in preterm infants, with the greatest changes occurring in the most preterm infants. These findings highlight the relationship between neurobehavioral maturation and feeding behaviors.

Delayed or impaired suck development may result from a variety of causes, including insult to the developing brain following hemorrhage or hypoxic-ischemic event, neurogenetic or craniofacial anomaly, feeding intolerance, surgery, diabetes, or ventilator interventions that interfere with ororhythmic pattern formation. Lengthy oxygen supplementation procedures in the NICU, for example, can have a negative impact on preterm infants with respiratory distress syndrome or bronchopulmonary dysplasia, costing them precious sensory and motor experiences during a critical period of brain development when suck and pre-feeding skills are being refined. Interruption of these vital experiences may impair fragile syntheses of how the brain maps these functions. Even the presence of a nasogastric (NG) feeding tube has negative effects on sucking and breathing. Trussing the lower face with tubes and tape restricts the range and type of oral movements and limits cutaneous experiences with the hands and fingers.

For some preterm infants, poor suck and oromotor discoordination persist into early childhood and are correlated with significant delays in the emergence of other oromotor behaviors, including feeding, babbling, and speech-language production. Infants who fail to establish oral feeding skills in the NICU may be sent home on gavage or G-tube feedings, which may hinder the development of coordinated oromotor behavior. The difficulties associated with establishing oral feeding competence—coupled with the additional costs for extended hospitalization—underscore the need for assessment and therapeutic tools that facilitate the development of normal oral motor skills

Feeding maturation

The Medoff-Cooper nutritive sucking apparatus (MCNSA) was used to measure infant feeding behaviour. The MCNSA is comprised of a premature nipple that has a flow-limiting device to deliver 30 ml/min at a constant 100 mmHg pressure. Silicone rubber-embedded calibrated capillary tubing is used for measuring metered nutrient flow. A second tube embedded in the silicone measures the intra-oral pressure and is connected to a pressure transducer. By ensuring viscous flow through the capillary, the instantaneous volumetric flow rate is maintained directly proportional to the pressure. Transducer output is recorded to a computer system and customized software was designed to capture the infant’s nutritive sucking behaviours.

Nutritive sucking behaviours were measured 15 min prior to a regular feeding. Feeding maturation was assessed as the change in each of the feeding variables between 35 and 40 weeks post-conceptual age. At 35 weeks, infants were assessed in the NICU and arrangements were made with the primary care nurse to schedule an assessment during a regularly scheduled feeding. At 40 weeks, mothers returned with their infants for the follow-up assessment. During each feeding, infants were awake and alert, and held in the arms of a nurse researcher or the mother during the feeding assessment. Feeding variables measured over 5 min at each time point included the number of sucks, number of sucking bursts, number of sucks per burst, time between bursts and maximum pressure generated during a suck (Pmax).

Feeding behaviour problems in infants born preterm

The difficulties that preterm infants have transitioning from tube to independent oral feeding lead to delayed hospital discharge, maternal stress and rising financial burden. Caretakers recognize that immature sucking, delayed swallow and/or uncoordinated suck, swallow and respiration are potential causes for oral feeding issues. Within each of these three functions, there are components that may mature at different times as we have shown in the development of the suction and expression components of sucking . Conceivable that the difficulty encountered by preterm infants to feed orally results from similar sequential maturation of sucking, swallowing, respiration and/or their coordination.

The level and rate of maturation of components within each of these functions as preterm infants advanced in their oral feeding. The roper functioning of sucking, swallowing and respiration occurs at two levels; first on the appropriate functional maturation and synchronization of the muscles implicated within each function and, second on the safe coordination between the musculatures of these different functions. Studies have demonstrated that individual and coordinated activities necessitate close interactions between different sets of muscles or musculatures. For instance, in the synchronization of sucking musculature, there is a close correlation between muscles from the perioral area for the generation of sucking pressure, the jaw for its opening and closing and tongue for bolus formation and its peristaltic transport to the pharynx. The oropharyngeal swallow similarly implicates the participation of a number of pharyngeal musculatures controlling anatomical structures; dysphagia ensuing when compromises in any of these constituents occur. During oral feeding, the mechanical generation of respiration involves the proper activation of the diaphragmatic, intercostal musculatures, as well as upper airway muscles from nose to glottis. To study these individual rhythmic activities, the existence of central pattern generators (CPGs) has been advanced. CPGs for sucking, swallowing, and respiration have been described anatomically in the medulla with distinct pools of motor neurons involved in the sequential and rhythmic movements of the individual functions. The regulatory feedback of CPGs is presumed to require intact sensory afferents signalling changes in environmental as well as physiologic conditions. In addition, in preterm infants, exchange of oxygen/carbon dioxide is not only threatened by the mechanical activity of the respiratory musculature, but also by their immature pulmonary function resulting from dysfunctional alveoli and higher alveolar recoil.

Safety in infant oral feeding implies minimal risk of aspiration and requires the adequate coordination of sucking, swallowing and respiration as the anatomical pathways for air and nutrients share the same pharyngeal tract. In addition to their individual rhythmic functionality, these three functions need to occur sequentially from the oral to pharyngeal to pulmonary phases. Swallow needs to occur during a safe phase of the respiratory cycle. Therefore, to assist in our understanding of the coordination of these three functions, it becomes advantageous to incorporate the concept of cross-systems interactions proposed by McFarland and Tremblay with that of CPGs. These studies support that mechanical maturation of oral feeding skills need to occur at the peripheral and central levels, i.e. muscles and central nervous system.

Exploring feeding behaviour problems reported by parents of premature infants during the first 12 months corrected age. There was a significant association between “gastrointestinal complications of prematurity” and parental reports of feeding behaviour problems at two and more evaluation times. No relationship was found with such variables as: group, child’s gender, method of feeding, mother’s postnatal depression, or other complications of prematurity. Six major categories of feeding problems were identified: 1)early regulatory problems, 2) pain and/ or excessive spitting, 3) insufficient weight gain, 4) poor eater, 5) difficulties introducing new taste or consistency, and 6) difficulties with introducing self-feeding. These categories occurred with varying frequencies depending on the child’s gestational age and the assessment time.

The results point to an interesting diversity and dynamics of feeding behaviour difficulties in babies born preterm. It was shown that extremely low gestational age as well as gastrointestinal complications of prematurity may contribute to increased parental reports of feeding behaviour difficulties. Further research is needed to disentangle divergent underlying mechanisms of different feeding behaviour problems and describe possible challenges they may imply to the child, parents and their relationship.

Multiple factors related to bottle-feeding performance in preterm infants.

A great deal of attention has focused on understanding preterm infant feeding behaviors and on strategies to support the preterm infant during this period; however, comprehensive descriptions of the feeding behavior of preterm infants that incorporate an examination of multiple subsystem levels are lacking.

Various physical indicators related to preterm infants’ bottle-feeding performance. Linear mixed-effects models were used to examine the relationship between bottle-feeding performance and the remaining variables. Postmenstrual age, weight at each observed feed, oral motor skills, feeding experience, and feeding techniques were found to be significant predictors of feeding performance at the .05 level.

Multiple factors, both intrinsic and extrinsic, play a role in determining an infant’s bottle-feeding performance. In addition to age and weight, the presently employed conventional criteria, oral motor skills, feeding practice, and feeding techniques also contribute to infants’ feeding performance. Arbitrary age (34 weeks gestational age) and weight criteria (1,500 g) should not be the only indicators for oral feeding.

Feeding patterns of full-term and preterm infants at forty weeks postconceptional age.

Little research exists that addresses the differences in feeding skills between preterm (PT) infants at term and full-term (FT) infants. The differences in sucking abilities of PT infants when measured at 40 weeks postconceptional age (PCA) and newly born FT infants. The sample consisted of 213 infants who were divided into three groups on the basis of their gestational age at birth. The Kron Nutritive Sucking Apparatus (KNSA) was used to examine the microstructure of sucking and feeding behaviors. There were significant differences among the three groups in several of the sucking variables: number of bursts, intersuck interval, sucks per burst, suck width, intersuck width, mean maximum pressure, and intersuck width/interburst width. The findings from this study demonstrate the importance of both maturation at birth and experience as factors influencing feeding behaviors.

Feeding readiness is often evaluated by an infant’s display of non-nutritive sucking and oromotor patterning. Suck appears in utero during the second trimester and is remarkably stable and well-patterned by 34 weeks post-menstrual age (gestational age plus chronological age) in a healthy preterm infant. The non-nutritive suck (NNS)—any repetitive mouthing activity on a blind nipple or pacifier that does not deliver a liquid stimulus —typically consists of a series of compression bursts and pause intervals. Each burst typically consists of several suck cycles that decelerate in rate over the first five cycles until a steady state of approximately 2 Hz is achieved. The maturation and coordination of the NNS precedes the suck-swallow-breathe pattern associated with the slower 1-Hz pattern characteristic of the nutritive suck.

Establishing a patterned NNS for the developing infant has many benefits, including growth, maturation, and gastric motility, and also decreases stress. NNS also improves behavioral state control pre-feed ( and post-feed, decreases the frequency of apnea and cyanosis, and improves breastfeeding scores. In addition, it accelerates swallow frequency and development with differential effects among infants with bronchopulmonary disease promotes development of specific sucking skills and enhances oral feeds. Morever, it accelerates the transition from tube to independent oral feeding  and is presumed to enhance the maturation of neural systems responsible for ororhythmic activity. Accurate assessment of oromotor discoordination in the preterm infant may also serve as a potent clinical marker for brain development and neurodevelopmental outcomes

Suck Central Pattern Generator

The mammalian suck is one the earliest-appearing somatic motor rhythms. In the fetus and late-gestation human infant, it is regulated primarily by a neural network known as the suck central pattern generator (sCPG), which consists of bilateral neural networks within the brainstem pontine and medullary reticular formation. Based on animal models, the minimal circuits for ororhythmic activity reside between the trigeminal motor nucleus and the facial nucleus in the brainstem  and are situated to function as premotor inputs to lower motor neurons. Among many fascinating features, the sCPG can be modulated by the sensorimotor cortex and cerebellum. This connection underscores the importance of careful posturing and orientation during clinical testing to help the infant regulate his or her behavioral state because the nature of descending and peripheral inputs to the sCPG will be affected by this regulation. The sCPG is highly responsive to oral stimulation (i.e., breast, pacifier, or bottle nipple; tactile and thermal touch; olfactory cues) and orocutaneous entrainment

During entrainment, the baby synchronizes his or her oromotor activity to an externally delivered, patterned orocutaneous stimulus. This process represents a powerful method of achieving neural synchrony among sensorimotor pathways of the orofacial system to drive suck development. Therefore, it is not surprising that stimulation of the lips and tongue is a common method used to evoke sucking

Future Applications

A new randomized controlled trial (RCT) funded by the National Institute on Deafness and Other Communication Disorders is underway to assess the effects of a new synthetic patterned orocutaneous stimulation technique designed to entrain the sCPG in human infants. This technique of oral entrainment stimulation mimics the temporal features of the NNS burst, including age-appropriate NNS burst length and the frequency-modulated component of suck typically observed during burst initiation. Using this technique, the infant’s pacifier is transformed into a “pulsating nipple” that resembles the temporal pattern of well-formed NNS bursts. Application of the oromotor entrainment therapy is correlated to the rapid organization of suck in preterm infants who exhibit poor feeding skills, including improved NNS burst structure, lower NNS spatiotemporal index measures (sCPG activity pattern invariance), and a shorter transition to oral feeds.

In the RCT underway, oromotor entrainment stimulation will be delivered as early as 30 weeks post-menstrual age among several groups of babies, including infants with respiratory distress syndrome, bronchopulmonary dysplasia, abdominal wall defects, or Down syndrome; infants who are small for gestational age or born to mothers with diabetes; and healthy preterm infants. Infants receive alternating three-minute blocks of low-amplitude (0.15 millimeter) patterned orocutaneous stimulation during a 20-minute period, typically paired with gavage feeds, up to three times per day for 10 days in the NICU until the infant attains 90% to 100% oral feeds for two consecutive days (depends on individual NICU feed criteria). This schedule helps the infant develop an association between pleasurable oral stimulation and satiation from nutrients entering the stomach. Infants are held in a developmentally supportive posture (Figure 2) with dimmed background/overhead lighting to promote eye contact with the developmental specialist. Stimulation and sampling of NNS behavior begins when the infant achieves a drowsy-to-active alert behavioral state (NIDCAP) (Als, 1995). Infants remain connected to their pulse-oximetry monitors at all times to ensure that respiration, pulse rate, and oxygen saturation levels are adequate to support oromotor activity.

Primary outcome variables include daily measures of non-nutritive suck dynamics, spatiotemporal index of the non-nutritive suck, ororhythmic motor behavior, NNS cycle period analysis, early feeding skills assessment, transition time from tube-to-oral feed, feeding efficiency, and length of hospital stay. A second major objective is to conduct a comprehensive assessment of neurodevelopmental outcomes at 3 years of age, using the Bayley III and standardized speech-language test instruments. More than 350 preterm infants will be included in the study.

Prematurity is a major factor leading to feeding and swallowing issues and may be further complicated by insults to the developing nervous system or the challenging environment of the NICU. A patterned oral somatosensory experience through entrainment of neural pathways supporting the orofacial system presents a new neurotherapeutic application for the habilitation of suck in premature infants. Repeated exposure to patterned orocutaneous concurrent with NG tube feeds facilitates the development and presumably strengthens neural networks that regulate suck. This intervention is non-invasive, safe, and pleasurable for the neonate, as well as quantitative and easily administered in the NICU. Entrainment therapy provides the infant with additional benefits, including improved behavioral state control pre- and post-feed, growth, maturation, and gastric motility, while decreasing stress and enhancing the transition to oral feeds.

Nutritive sucking and neurobehavioral development in preterm infants

Changes in nutritive sucking patterns, behavioral state, and neurobehavioral development of preterm infants from the 34 weeks postconceptional age (PCA) to term. There were significant differences in number of sucks, intensity of sucking pressures, average time between sucks, and average time between bursts  from 34 weeks PCA to term. With maturation, it was noted that the preterm infants were significantly more alert during the sucking protocol from 34 weeks to term (p < 0.001). Yet, infant sucking parameters at 34 weeks PCA and term were not significantly related to the BNBAS or to the infant’s state.

These results demonstrate that high risk preterm infants mature significantly in their sucking behaviors and in their ability to maintain a more alert behavioral state from 34 weeks PCA to term. However, unlike full term infants–where state is positively correlated to feeding (sucking) success–the preterm infant state of alertness may not enhance sucking skills at 34 weeks PCA. These infants may be too stressed to manage both feeding and stimulation from the environment that is unavoidable when alert. However, this relationship does appear to change by 40 weeks PCA.

Medolf also reported that  high risk preterm infants mature significantly in their sucking behaviors and in their ability to maintain a more alert behavioral state from 34 weeks PCA to term. However, unlike full term infants–where state is positively correlated to feeding (sucking) success–the preterm infant state of alertness may not enhance sucking skills at 34 weeks PCA. These infants may be too stressed to manage both feeding and stimulation from the environment that is unavoidable when alert. However, this relationship does appear to change by 40 weeks PCA.

Non-nutritive sucking for promoting physiologic stability and nutrition

Non-nutritive sucking is used during gavage feeding and in the transition from gavage to breast/bottle feeding in preterm infants. The rationale for this intervention is that non-nutritive sucking facilitates the development of sucking behaviour and improves digestion of enteral feedings. Non-nutritive sucking has been considered to be a benign intervention, although it has the potential to have a negative effect on breastfeeding or on the incidence of later oral aversion.

Whether non-nutritive sucking (NNS) in preterm infants influences:  weight gain, energy intake, heart rate, oxygen saturation, length of hospital stay, intestinal transit time, age at full oral feeds, or any other clinically relevant outcomes. This significant decrease in length of stay in preterm infants receiving a NNS intervention. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, age at full oral feeds and behavioral state). Other positive clinical outcomes of NNS: transition from tube to bottle feeds and better bottle feeding performance. No negative outcomes were reported in any of the studies. There were also a number of limitations of the presently available evidence related to the design of the studies, outcome variability, and lack of long-term data. Based on the available evidence, NNS in preterm infants would appear to have some clinical benefit. It does not appear to have any short-term negative effects. order to facilitate meta-analysis of these data, future research in this area should involve outcome measures consistent with those used in previous studies. In addition, published reports should include all relevant data.

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