Feeding in the NICU and
Beyond
Jennifer D’Attilio, M.S., CCC
Director, Speech and Language Services
Central Coast Language and Learning Center
Monterey, California
Roles and Responsibilities
Developmentally Supportive Care
 Team Member of Interdisciplinary Team
 Family priorities
 Cultural Factors
 Family in Crisis

Neurodevelopmental Care
Philosophy of Care
 Supports Infant/Parent Relationships
 Supports Neuromaturation
 Minimizes Adverse Stimuli

Goals
Developmentally Supportive Care
Vulnerability to sensory overload
 Sensory overload is seen in physiologic,
motor, state, and attention behaviors
 Caregivers must watch, recognize and
respond to the cues to help the infant
maintain and or/ regain self-regulation
 Caregiver can help the infant maintain
regulation and learn self-regulation

Fundamentals of Developmental
Care
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Providers of direct hands-on care must be
free of perfumes, colognes, oils, lotions, etc.
Caregiving based on infant cues
Provide two-person care giving with
procedures whenever possible, promoting
self-regulation.
Provide developmentally supportive
positioning (midline positioning, flexion,
containment, comfort)
Developmentally Supportive Care
Modifying the environment
 Modifying the caregiving
 Responding contingently to infants'
behavioral cues which can signal stress
versus stability

The Synactive Theory of Infant
Development; Heidi Als, Phd
provides a framework for understanding
the behavior of premature infants. The
infant's behaviors are grouped according to
five "subsystems of functioning."
The Synactive Theory of Infant
Development
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MOTOR - Infant's motor tone, movement, activity and
posture.
AUTONOMIC - The basic physiologic functioning of our
body necessary for survival. The easily observable indicators
of this subsystem are skin color, tremors/startles, heat rate
and respiratory rate.
STATES -A way of categorizing our level of central nervous
system arousal - sleepy/drowsy, awake/alert and
fussing/crying.
ATTENTION/INTERACTION - The availability of the infant
for interacting, alertness and the quality of the interaction.
SELF-REGULATORY - This is the presence and success of the
infant's efforts to achieve and maintain a balance of the other
four subsystems.
Interaction among subsystems
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•
Each subsystem can be described independently,
yet functions in relation to the other subsystems.
The autonomic system has to be functioning (the
baby breathing and has a heat rate) to be able to
assess an infant's ability to look at something and
engage
How the five subsystems work together or
influence each other is key to the theory
We as providers attempt to view the infant's
continuous interaction with the environment and
educate caregivers
Timing is everything in
developmentally supportive care
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The basic concept underlying this approach is that the infant
will defend him/herself against stimulation if it is
inappropriately timed or is inappropriate in complexity or
intensity.
If an inappropriate stimuli persists the infant will no longer
be able to maintain a stable balance of subsystems (e.g.,
decrease or increase in heart or respirations may be
observed or skin color may change, or muscle tone decrease,
shutting down).
When properly timed and appropriate in complexity and
intensity, stimulation will cause the infant to search and move
toward the stimuli, while maintaining him/herself in a stable
balance (e.g., appropriate color, even heart and respiratory
rate and/or good muscle tone).
Developmentally Supportive
Care
The earlier the gestation the less self-regulatory
behaviors the infant has available, and the more
the infant has to rely on outside help in regulation
Signs of Stability
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•
•
Autonomic: heart rate, blood pressure, respiratory
rate, oxygen saturation, skin color
Motor: smooth motor movements, flexion,
grasping, hands to face/mouth, foot bracing
State: nice transitions between deep sleep, light
sleep, drowsy, quiet alert, active awake, crying
Flexion, hands to mouth, quiet alert
What we see in the Preterm

In the preterm infant these systems are not fully
developed or ready to function. Therefore, the
preterm infant's behaviors are generally
characterized by disorganization and signs of
stress. The preterm infant is more dependent,
than the full term infant, on its environment to
help support and maintain balanced equilibrium.
Necessary technology focuses care on the
autonomic system (respiratory, cardiac, digestive
etc.), yet comes at the expense of the motor,
state, and self-regulatory systems, which are
dependent on environment.
Autonomic Signs of Stress
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Color changes, flushing (turning red), and
cyanosis (turning blue)
Changes in vital signs (heart rate, respiratory
rate, blood pressure (BP), pulse ox rate)
Visceral responses (vomiting, gagging,
hiccups, passing gas)
Sneezing
Yawning
Tremor and Startle
Motor Signs of Stress
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Generalized hypotonia (limp, decreased resistance
to moving of the infant's extremities)
Frantic flailing movements
Finger splaying (holding fingers spread wide apart)
Hyperextension of extremities (arms or legs
extended straight out almost in a locked position)
State Signs of Stress
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Irregular sleep states (lots of twitching, grimacing,
not resting peacefully)
Gaze aversion (moves eyes to the side trying not
to look at what is in front of them)
Staring (a locked gaze, usually wide open eyes)
Panicked look
Irritability (hard to comfort)
Gaze aversion
Attention/Interaction Signs of Stress
Inability to integrate with other sensory
input (can't look and face, listen to talking
and suck a bottle at the same time)
 Will not appear to want to engage with
caregiver

Supporting Strategies when
signs of Stress are seen
Grouping care activities - This should
enable infants to have longer periods of
quiet.
Appropriate Timing of Care - Use
swaddling, prone or side lying supported
positioning to help a infant
Supporting Strategies when
signs of Stress are seen
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Separating feeding and socializing: Coordinating
sucking, swallowing and breathing may take all the
energy and concentration the infant
Feeding should be quiet and calm
Slow the pace of what you are doing or give the
infant a break if signs of stress are noted.
Use of positioning and containment devices,
dandelion, swaddling and other supports to help
keep the infant in a comfortable flexed position
Kangaroo care

seeks to provide restored closeness of the
newborn with mother or father by placing
the infant in direct skin-to-skin contact with
one of them. This ensures physiological and
psychological warmth and bonding. The
kangaroo position provides ready access to
nourishment. The parent's stable body
temperature helps to regulate the neonate's
temperature more smoothly than an
incubator, and allows for readily
accessible breastfeeding
Kangaroo care
Parent/Family Interaction
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Allowing the parent more involvement in care
Allowing the parent and child to interact and
communicate for pre-feeding and feeding activities
Relationship based feeding experience
Infants Predisposed to sensory
based feeding disorders
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•
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Infants with chronic lung
disease/bronchopulmonary dysplasia
Infants with cardiac defects
Drug exposure
Gastrointestinal needs: reflux, TE fistula, esophageal
atresia, pyloric stenosis
Infants who have been intubated, prolonged NG
tube
Medical Conditions and Impact on
Feeding
The total number of medical
complications and co-morbidities
correlates significantly with length of
transition time from gavage to full nipple
feedings (Medoff-Cooper, 1983; Ross
2008)
 Respiratory and cardiac co-morbidities
significantly predict transition time:
negatively impact ability to coordinate SSB
(Gewoib and Vice, 2008)

Nutritional and Gastrointestinal
Issues
Emesis
 Irritability
 Arching
 Dry swallowing, coughing/choking
 Reluctance to feed
 Apnea and/or bradycardia

Developmentally Supportive Care
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Signs of stability during feeding ( Shaker
1999)
◦ Smooth regular respirations
◦ Hands active in midline, hands near face, good
postural control
◦ Organized and calm
◦ Focused and alert
◦ Good coordination of suck-swallow-breathe
Developmentally Supportive Care
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Signs of stress during feeding (Shaker,
1999)
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Change in state of alertness
Change in color
Change in breathing
Change in postural control
Disruptions in swallowing
Infant Cue-Based Feeding
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Main goals
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Medically safe
Functional
Relationship-based
Individualized
Steering away from volume driven feeding
cultures
Goals
Attempt to support the infant as a
successful feeder, not a successful feeding
( Shaker, 1989)
 Recognize and respond contingently to
the infants communication during feeding
and communicate that to parent/caregiver
 Use a Gentle Feeding Approach ( Thoyre)
based on continuous feedback from the
infant

Feeding Assessment and Swallowing
Taking a History
Gestational Age: ( GA) –more predictive
of feeding success than PCA (Amizu et al,
2007)
 Post Conceptional Age ( PCA)
 Birthweight
 Birth Circumstances
 Apgar Scores ( cry, color, tone,
respiratory rate, heart rate)
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Before Feeding
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Medically predisposed to feeding disorders
Family
Environment
Sound, light, support staff
Sensory Based Feeding Disorder

Infants predisposed to the above include
◦ Chronic lung disease: trouble breathing,
uncoupling of the SSB pattern, open mouth,
tongue posture forward, aversion to having
airway occluded
◦ Cardiac Defects: uncoupling of SSB, fatigue
easily, require more calories per kilogram of
weight to grow
◦ Drug exposure: poor sensory integration,
poor adaptability, perseveration with feeds
Sensory Based Feeding
GI issues: reflux, tracheoesophageal fistula,
esophageal atresia, poor/delayed gastric
emptying, pyloric stenosis, dysmotility
 Extended intubation, suctioning, oral
gavage, nag tube feeds

NICU classifications
GA Gestational Age:
37-42 wks: term
28- <37 wks: preterm
Under 28 wks: extremely preterm
Over 42 wks: post-term
NICU Classifications
Birth Weight
Over 2500 gm: average neonatal BW
1500-2499 LBW
1000-1499 VLBW
Under 1000 gm: ELBW
Progression of Sucking
28 wks: oral reflexes
 32 weeks: gag reflex
 34 weeks: SSB coordination
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Neuromotor Assessment
Tone: infant movements during active
movement and during passive movement
during interventions
 Neuromotor reflexes: sucking, palmar
grasp, recoil upper and lower, plantar
grasp, popliteal angle, head lag

Readiness to initiate nippling
Autonomic stability
 Maturation/function of the GI tract
 Successful feeders spend more time in a
quiet/alert state
 State modulation
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◦ Ability to self-regulate
◦ Postural control
◦ Respiration and work of breathing- cost of
feeding
Tube feeding
Tube Feeding /Gavage
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NGT: nasogastric tube: tube is paced
through the nares down the esophagus and
into the stomach
◦ Less than one month

OGT: orogastric tube: tube is placed through
the mouth into the stomach
◦ Short term
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PEG Tube: percutaneous endoscopic
gastrostomy: incision through the abdomen
into the stomach
◦ Long term nutrition
Bottle Feeding
Breast Feeding
Developmental Handling
Prepatory touch
Facilitative tuck
One hand on the infant at all times
Movements are planned
Ready to Assess
Postural Control
 Muscle tone
 Ability to cope with stress during feeding
 Successful feeders spend more time in
quiet/alert state (McCain, 1997)

Ready to Assess
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Regulation of breathing
◦ Severity of respiratory complications
lengthened the time to achieve full oral
feedings ( Craig et al, 1999)
◦ Impact of chronic lung disease
◦ Cardiac and respiratory status at baseline
versus during intervention
◦ WOB: RR, retractions, nasal flaring, chin
tugging
Feeding Assessment

Neonatal Oral-Motor Assessment Scale
(NOMAS) © 1990 Marjorie Meyer Palmer
Infant Driven Feeding (Ludwig &
Waitzman)
 Early Feeding Scales ( EFS)
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(Thoyre, Shaker)
Assessment

NOMAS®: Neonatal Oral-Motor
Assessment Scale
◦ Developed by Marjorie Meyer Palmer
◦ Separates 13 characteristics of jaw movement
and 13 characteristics of tongue movement
into categories of normal, disorganized, and
dysfunctional
Mature Suck
Mature and Coordinated
 Consistent
 Strong and efficient
 Normal rate and rhythm
 Normal sensory state
 Ability to adjust to sucking rhythm

Disorganized
Immature and uncoordinated
 Inconsistent
 Poor rhythm
 Inconsistent rate
 Difficulty adjusting to flow
 Variation in number of bursts- 36-10-7
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dysfunctional
Abnormal tongue and jaw movement
 Neurological involvement
 Hyper or hypo tonic oral motor
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Early Feeding Skills
Thoyre, Shaker, and Pridham, 2005
 Checklist for assessing infant readiness
for and tolerance of feeding
 Profiles the infants developmental stage
regarding specific feeding skills
 Assess the ability to
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Maintain physiologic stability during feeding
Remain engaged in feeding
Organize oral-motor function
Coordinate swallowing with breathing
Bottle versus Breast Feeding
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Breast Feeding
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Delayed initiation of NS
Inconsistent SSB ratio
Wide variability in number of sucks per burst
NNS occurs intermittently during NS
Bottle versus Breast Feeding
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Bottle
◦ Spontaneous initiation of NS
◦ Consistent ssb ratio
◦ Limited variability in the number of sucks per
burst
◦ NNS does not occur during NS
Non-Nutritive Suck
During gavage feedings
 Not a predictor of success with nipple
feedings (Lau, 2001)
 Stages

◦ 27-28 weeks: weak single sucks with long
variable pauses
◦ 30-33 weeks: short but stable sucking bursts
with long irregular pauses
◦ 37 weeks: same as term infants: intermittent
after 5-6 sucks
Nutritive/ Non-Nutritive
◦ NNS:
◦ 2 sucks per second
 Ratio of 6:1
 NS:
SSB coordination
1 suck/second
1:1 ratio
Sucking
Fluid is moved by changes in pressure
 Positive pressure/compression pushes
fluid out the nipple
 Negative/suction draws fluid out
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Nutritive Sucking
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Suck swallow breathe coordination
Influenced more by GA than PCA ( Amaizu
et al, 2007)
Ratio of 1 suck to 1 swallow predominates
until > 40 weeks PCA; then 2-3 sucks per
swallow
Progression of preterm to term is
◦ Increase sucking and swallowing rates
◦ Longer sucking bursts
◦ Larger volumes per suck
Normal bottle feeding
Feeding and Swallowing Assessment
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Swallowing stress signals reflecting
uncoupling of the suck-swallow-breathe
pattern
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Gulping
Drooling
Gurgling sounds in the pharynx
Coughing/choking
Signs of distress; hand splaying, eyebrows
furrow, chin tugging, head turning
Assessment
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Stress Signals
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Gulping
Drooling
Gurgling sounds
Coughing
Limited jaw movements
Compression only sucking
Use of purposeful weak sucking
Physiologic Changes during Feeding
are key in assessment

Responses to the work of feeding may
result in negative changes in physiologic
responses
◦ In heart rate, respiratory rate, oxygen, and
color
Organic versus functional
Impact of respiratory change/compromise
 Increased respiratory drive can inhibit
oral feeding ( Timm et al, 1983)
 CLD: may use a weak suck pressure to
reduce respiratory work and maintain
breathing on purpose ( Mizuno et al,
2007)

Respiration and Feeding
Relationship between suck-swallow-and
breathing matures with increasing PCA
Feeding may override respiratory
chemical control
 Decreases in oxygenation during feeding
provide infant with negative feedback and
result in loss of coordinated feeding
behavior as infants attempts to protect
airway
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Signs of Uncoupling in Feeding
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Breathing stress signals reflecting
uncoupling of the swallow and breathe (
Shaker, 1999)
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Respiratory fatigue
Tachypnea
Nasal flaring
Chin tugging
Reliance on catch-up breaths
stridor
Cyanotic: blue or purple
Oxygenation and Feeding
Percentage of 100
 Will fluctuate during feeding
 Preterms will continue to feed and not
stop to breathe
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Compensatory Strategies
Drooling/Anterior Spillage
 Small jaw excursions
 Compression only
 Purposeful weak sucking pattern ( Mizuno,
2007)
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What to do now?
Lau Study
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Lau et all (1997) infants given a restricted
flow fed more fluid per feeding than
infants given unrestricted flow
Intervention
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Flow rate: one of the most critical
considerations for safe feeding
High flow rate may flood the pharynx,
trigger repeat swallow and interrupt
breathing
High flow rate nipples by formula companies
Ventilation decreases as flow rate increases
Decrease in ventilation can cause apnea
and/or bradys
Nipple Selection
Regular Flow
 Slow flow
 Fast flow
 Mimics breast
 Parent involvement
 Cleft palate
◦ Haberman ( Special Needs Feeder)
Positioning
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Semi-Upright
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Breathing
Alignment
Gravity
Flow rate
Side-lying
Increased lung compliance
 Increased rib cage movement
 Increased o2 saturations, less bradycardia
 Control of fluid
 Mimics breast feeding

Chin Support
Increases stability
 Increases awareness around rhythmical
jaw excursions
 Increases latch/ suction
 Increases flow rate and bolus size
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Pacing
Supports improving burst/pause rhythm
 Breathing increased in regulation
 Bolus control
 Safety
 Increased ability to stay with the
successful feeding
 technique
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Consistency with Care
Communication with parent/caregiver
 Consistent caregiving
 Sharing information and reasoning
 Follow up
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Clinical signs/symptoms of
aspiration
Poor weight gain
 Poor respiratory status
 Refusal to feed
 Bradycardia, desaturations
 Stridor
 Wet, gurgly vocal quality
 Dusky
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Signs and symptoms of distress
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Finger splaying
Eyes widening
Head turning
Chin tugging
gulping
Outcomes related to feeding
31% of NICU graduates will experience
feeding difficulties prior to one year of
age
 40% of children referred to an outpatient
clinic for feeding or growth concerns are
former preemies

◦ (Hawdon et al 2000)
Feeding Disorders in Infancy
Feeding problems affect approximately
25% of infants and young children
 Severe feeding disorders including poor
weight gain, refusal to eat, or emesis affect
1-2% of infants under the age of 12
months

◦ 70% of those affected will have persistent
feeding difficulties until 4 to 6 years of age
 Chatoor, 2002
Beyond the NICU
After Discharge
Limited support systems
 Communication with physician
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Length of and amount of feeding
GI consults
Nutrition consult
Nicu course if possible
After the NICU
Family resources
 Ability to follow through
 Support for outpatient services
 Our role and responsibility
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After Discharge
Normalize oral-sensory environment
 Oral aversions-tubes, tape
 Inconsistent feeding approaches
 Force feeding
 Nutrition- weight gain
 Weaning tube feeding
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Goals for Feeding Therapy
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Relationship between health and feeding
Relationship between child and caregiver
Oral, respiratory, neurologic systems within
a child should be examined carefully
Normalizing the ability to accept and
integrate visual, auditory, tactile, balance,
taste, and temperature is necessary before
direct facilitation of new oral feeding
patterns
Oral sensorimotor treatment may be
included during a child’s play, mealtime, tooth
brushing
History…Again
Medical and Feeding History
 Developmental History
 Sensory Evaluation
 Positioning/Tone
 Oral Motor/Swallowing Evaluation
 Nutritional Assessment
 Behavioral Assessment

History….Again
Respiratory Complications
 Cardiac Issues
 Aspiration/Dysphagia
 Food Allergy
 Tracheomalacia/Laryngomalacia
 TE fistula/ atresia
 Craniofacial Anomalies
 Sensory/Hearing/Visual Deficits

History Again
Seizure Disorder
 Anxiety Disorders
 Sensory Processing
Disorder/Developmental Delays
 Failure to Thrive
 Digestive Tract Disorders

Respiratory History
RDS
 BPD
 Frequent colds
 RSV
 Wheezing
 Asthma
 PNA
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Gastro-Intestinal History
Digestive tract disorders will play a
significant role in feeding
 Reflux:

◦ May be silent and trigger a vasovagal response
resulting in apnea and bradycardia
◦ Reflux can also result in gastric aspiration
◦ Reflux may also impact the nasopharyngx
creating increased bacteria in nasal secretions
◦ Reflux may cause damage to the vocal cords
or cause esophagitis
GI and Feeding Disorders
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Reflux may lead to esophagitis
Gastro esophageal reflux may lead to gagging
, emesis, choking
The above may lead to avoidance
◦ Crying, gagging, vomiting, turning head, throwing
food

The avoidance of foods and above lead to
parents response
◦ Food selectivity, escape from meals, force feeding
◦ Cycle feeding
Feeding Assessment
What is the intake schedule
 Products used
 Observe feeding with patients food and
products if possible
 Observe before, during and after feeding
 Use video when appropriate

Daily Intake
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Communication and Interaction and cue based
responses during feeding
What is put in front of the child, when, how often
Any meal is better than another-poor am
intake/reflux
Favorite and least favorite foods
Did the child mouth toys, enjoy things in the
mouth-oral hypersensitivity
Daily output
Sleep patterns
Behavior
Previous Interventions
Assess the foods
Color
 appearance, shape, texture
 residue
 smell
 texture
 changes during feeding, during and after
 flavors
 temperature

Formal Assessments /Scales
Holistic Feeding Observation Form (
Koontz-Lowman & Lane, 1999)
 Schedule of Oral Motor Assessment (
Reilly, Skuse, & Wolke, 2000)
 Multidisciplinary Feeding Profile ( Kenny
et al, 1989)
 Beckman Oral Motor Assessment

Posture and Swallow

Optimal Feeding
◦ Neutral Head Position with balance between flexion and
extension
◦ Neck elongation
◦ Symmetrical shoulder girdle stability and depression
◦ Symmetrical trunk elongation
◦ Pelvis stability
◦ Hips, knees and ankles at 90 degrees

Oral Motor Assessment
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Root-stroke down on lower lip
Phasic bite-rub gum ridge
Transverse tongue-touch side of the tongue
Gag
Strength and ROM in tongue, lips, jaw
Assessment
Assessment
Sensory
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Nipple confusion with
breast and bottle
Poor differentiation in taste
Manages liquids better than
solids
Able to sort food out in a
mixed texture
Holds food under tongue
or in cheek to avoid
swallow
Motor
Inefficient suck with breast and
bottle
Can differentiate taste in a
bottle
Oral motor inefficiency and
incoordination in all textures
Unable to hold or manipulate
bolus on tongue; food falls out
into cheeks
Differentiation between Sensory
and Motor
Sensory
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Motor
Vomiting only certain
textures
Gags when food
approaches or touches lip
Hypersensitive gag with
solids ; normal liquid
swallow
Tolerates own fingers in
mouth, does not accept
other’s
Does not mouth toys
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Vomiting is not texture
specific
Gags after food is moved
through the oral cavity
Gags with liquids and solids
after the swallow is
triggered
Tolerates other fingers in
the mouth
Accepts teething toys,
unable to bite
Palmer, Heyman, 1993
Advantages
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Moblie
Immediate examination
No radiation
Position of patient is easier
Evaluate structure and
function of hypopharynx
and larynx possible
Study as long as needed
disadvantages
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Incomplete evaluation of
pharyngeal phase
Only can visualize
immediately before and
after swallow
No assessment of oral or
esophageal phase
No coordination of
pharyngeal motility with
tongue, laryngeal elevation
Flexible Endoscopic Evaluation
of Swallowing with Sensory
Testing ( FEES)
Video fluoroscopic Swallow Study
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Oral phase bolus handling
Velopharyngeal function, nasopharyngeal function
Laryngeal elevation and hyoid bone movement
Vocal fold function
Pharyngeal motility and transit time
Pooling of secretion in valleculae and pyrifom
sinus before swallow
Number of swallows necessary to clear
Residue
( Arvodsen, Brodsky 2002)
What we see
Oral Phase Trouble
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Poor lip seal
Poor bolus formation
Poor tongue grooving
premature spillage-base of
tongue
Poor base of tongue
movement
flow
Interventions
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Pacifier training program
Beckman Oral Motor®
Program
Nipple change
Pacing
Positioning to support
Sensory aspects of food
Tongue exercise
Stages of Swallowing and
Interventions
Pharyngeal Phase
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Vocal cord paralysis
Pooling in the valleculae
and pyriform sinuses
Laryngeal penetration
Aspiration
Gurgly voice quality
Interventions
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Cold bolus, flow rate
Pacing, side-lying
Tube feeding and
therapeutic feedings
Improve oral stage to
improve bolus propulsion
Stages of Swallow and
Intervention
Esophageal Phase
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GER
Esophagitis
Esophageal atresia
Intervention
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GI referral
Reduce flow rate
Breast feeding
Medication
Formula change
Stages of Swallow and
Intervention
Oral Sensory Management/
Desentization
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Tolerating- food in the same room, looking at
food,
Interacting-uses utensils, stir or touch food, but
not in the mouth
Smelling-tolerates the smell of food
Touch-fingers, hand, chin, cheek, lips, teeth, tongue
Taste-licks bites and spits out, bites and holds,
chews and swallows with a drink, chews and
swallows independently
Eating- functional eating
Varied textures
Transitioning to Table Foods
Formula/Breast Milk until??????
 Baby food at 6 months
 Transition at 9-10 months
 Table foods at 12 months
 Foods help a child learn to eat however
the baby continues to get nutrients from
formula/breast milk
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Introducing the Spoon/Self Feeding
Pacifier can be used, weighted spoons,
divided plates
 Feeding Environment
 Feeding pressures
 Meal time routines
 Chair and positioning
 Portion sizes and what is in view
 What is being offered
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Spoons
Oral Motor as part of the Program
Beckman Oral Motor®, Food Chaining
 Z-vibe, jigglers, Nuk brush, Duo Spoon
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◦ Use with care and know why and how you
are using them and what is the outcome for
the use of them
Food Chaining
Therapy is fun
 Known expectations
 Family input and understanding
 Knowing clear expectations
 Teaching the child about foods
 Never pushing a child to eat
 Rating reactions to foods
 Allow child to investigate foods from the
beginning to end
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Putting it all together
“Building a successful feeder, not a
successful feeding”, Catherine Shaker
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Resources
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National Association of Neonatal Therapists
www.neonataltherapists.com
NOMAS International
www.nomasinternational.org
ASHA: Roles of speech-language pathologist in the neonatal
intensive care unit
National Association of Neonatal Nurses
www.nann.org
Feeding and Swallowing Disorders in Infancy; Assessment and
Management, Wolf and Glass
Pediatric Feeding and Swallowing, Arvedson and Brodsky