Understanding and supporting the neurodevelopmental process of eating
Erin Sundseth Ross, PhD., CCC‐SLP
Erin Sundseth Ross, Ph.D., CCC‐SLP
Homeostasis
 Financial Disclosures:
 Intellectual Property and Salary, Feeding Fundamentals, LLC
 The ability to maintain internal regulation in the face of increasing challenges and demands (internal and external)
 Non‐Financial Disclosures:
 Board Member, Medical Professional Council, Feeding Matters
 First task is to establish internal regulation. This means, establish body function after birth.
 Once internal regulation is established, external demands can be slowly introduced
 Digestion of food
 Tolerance of environment
 Developmental activities (e.g., feeding)
© 2007‐2016 Feeding FUNdamentals, LLC Objectives
The SOFFI MethodSM Framework
 Describe at least 2 evidence‐based strategies that support infant regulation prior to the initiation of breast and bottle feeding attempts
 “Feeding” begins with establishment of homeostasis
 Define suction and compression
 Describe at least 2 caregiver interventions designed to support skill, efficiency or endurance during feedings
 Caregivers mindfully support the infant’s internal regulation from birth
 Environmental Demands
 Step‐wise progression towards eating
 Stability (across all systems) is monitored and interventions are applied based upon observable behaviors that indicate the need for support
 If stability is too challenged, homeostasis may be lost, and in this case the feeding is stopped.
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Physiologic Stability
 Assess and correct physiologic issues as thoroughly as possible:
 Respiratory
 Oxygenation
 Gastro‐Intestinal
 Consider maturation AND morbidity
 Implement strategies to protect physiologic stability once feeding is initiated (SKILL)
 At a minimum, do NOT create instability
Environment
 Challenge for infant, family and staff
 Provide a space for the family
 Adjust lights/noise/stimulation as needed.
 Quiet room
 Limited activity
 Dimmed lighting
 Lack of distractions
© 2007‐2016 Feeding FUNdamentals, LLC Organize the infant from birth
 Developmentally supportive care organizes the infant:
 Physiologic stability
 Motor stability
 Behavioral State stability
 Attention/Interaction stability
 The Newborn Individualized Developmental Care and Assessment Program has focused on improving overall health and development of infant
 Outcomes show improvements in oral feeding and decreased length of stay compared to controls
Als, et al., 2003
Environmental Influence on Feeding
 52 mothers, 19 fathers, 102 staff interviewed
 The core idea of 'the room environment for an attuned feeding'  the level of 'ownership' of space and place  the feeling of 'at‐homeness'  the experience of 'the door or a shield' against people entering, for privacy, for enabling a focus within, and for regulating socialising  'window of opportunity’  Construction and design of space and place was strongly influential on the developing parent‐infant relationship and for experiencing a sense of connectedness and a shared awareness with the baby during feeding, an attuned feeding. © 2007‐2016 Feeding FUNdamentals, LLC Flacking and Dykes (2013)
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Kangaroo Mother‐Care
Improved Breast feeding Outcomes
 Enhances bonding and attachment
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 Reduces maternal postpartum depression symptoms
 Enhances infant physiologic stability and reduces pain
 Increases parental sensitivity to infant cues
 Contributes to the establishment and longer duration of breastfeeding  Has positive effects on infant development and infant/parent interaction
251 preterm infants, Iran
All mother’s given education for KMC
62.5% mothers performed KMC
Exclusive breastfeeding at discharge:
 62.5% for KMC
 37.5% for those mother’s who decided not to KMC
 p = .00
 4.1 time increase in exclusive breastfeeding by KMC
 Weekly increase in GA increased exclusive breastfeeding by 1.2 times
Heidarzadeh, et al., 2013
Nyqvist, et al., 2010
Kangaroo Mother Care
 Compared to control T and PT infants, PT held in KMC for 1 ½ hours per day, 4 days per week, for 8 weeks, EEG recordings showed:
 Fewer REMs
 Increased quiet sleep
 Increased respiratory regularity
 Longer cycles
 Three right hemispheric regions had greater complexity  Compared to PT controls:
 Fewer REMs
 Greater arousals
 More quiet, sleep in the SSC group.
Scher, et al., 2009;
Kaffashi, et al., 2013
 KMC accelerates brain maturation
© 2007‐2016 Feeding FUNdamentals, LLC •Consider using the mother’s breast pads
as part of the infant’s bedding
•Provide the family with a cloth/scarf to
wear, to provide comforting smells
•Encourage skin-to-skin holding
•Consider using mother’s milk/colostrum
for oral care
•Promote family involvement during
feedings
© 2007‐2016 Feeding FUNdamentals, LLC Improved Breastmilk Outcomes
© 2007‐2016 Feeding FUNdamentals, LLC Breastmilk Odor and Growth
Variable
Control
Study
 Improved exclusive* breastfeeding rates from 0% Gestational Age at Birth (n=80)
31.27
31.05
.49
in control group, to 83% at discharge (Almeida, et al., 2010);
 Improvement from 60% exclusive* breastfeeding and 3% providing 50‐80% of feedings with breastmilk, to 72% and 8% in group receiving KMC (Hake‐Brooks & Anderson, 2008).
Weight at birth
1,606
1,466
.07
 With programs of Kangaroo Mother Care (KMC)
Weight at total oral feeding
1,699
1,561
.02
Weight at discharge
1,922
1,893
.05
Weight gain during hospitalization
335
427
.06
Duration of hospital (days)
23
18
.008
Yildiz, et al., 2011
* Exclusive includes breastmilk in bottle and breastfed
© 2007‐2016 Feeding FUNdamentals, LLC P value
© 2007‐2016 Feeding FUNdamentals, LLC 3
Non nutritive sucking
• Assess infant’s subtle hunger cues
• Document rhythmicity of state change
• Consider holding the infant and offering NNS during
enteral feedings
• Infants can suck on their own fingers, a pacifier, or a
small finger offered by a caregiver
• Placing a small amount of milk on the infant’s fingers
may also help the infant to associate pleasant smells
and tastes with hands to mouth activity
© 2007‐2016 Feeding FUNdamentals, LLC Non‐nutritive sucking as a “therapy”
Infant Suck Characteristics
 Compared to an oral‐stimulation program:
 Weight gain was better in infants with NNS as therapy intervention
 No difference in PMA at full oral attainment for NNS, Oral Stimulation, or Control groups
 Infant sucking has two characteristics
 Compression
 Suction
 Compression (mouthing) is a vertical positive pressure on the breast or bottle, which pushes fluid out
 Note: Control group received “sham” intervention – NO TOUCHING, LEFT IN ISOLETTE.
 Suction is a negative pressure, which pulls fluid out
Asadollahpour, et al., 2015
 Suction requires a seal around the breast or bottle that is maintained when the jaw moves downward, creating a vacuum effect.
 Volume is driven by suction.
© 2007‐2016 Feeding FUNdamentals, LLC Non‐nutritive sucking  Largest body of evidence to support benefits
 No evidence of detrimental effects
 Decreases significantly the length of hospital stay in preterm infants
 Supports transition from tube to bottle feeds
 Bingham, et al (2010)
 La Orden Izquierdo, et al (2012)
 Liu, et al (2013)
 Supports better bottle feeding performance
Harding, 2009; Pinelli & Symington, 2005
© 2007‐2016 Feeding FUNdamentals, LLC POSITIVE PRESSURE
NEGATIVE PRESSURE
© 2007‐2016 Feeding FUNdamentals, LLC 4
To support positive experiences with feeding
Skill
 Support SKILL (coordination) first!
 Skill is defined as calm, safe coordination of  Look to stability signs to determine readiness for and influence of feeding
 Implement feeding supports to decrease demands and facilitate skill development
experiences that improve skill, efficiency and endurance
Feeding Model for SOFFI MethodSM
• Physiologic Stability
• Motor Stability
• Behavioral State Stability
Feeding Challenge
• Maintain stability in the face of the additional external challenge of feeding
• Stability and Instability are communicated by the infant through their observable behaviors
efficiency
 Positioning supports organization of suck/swallow  Focus on experience – volume is a natural outcome of Baseline Homeostasis
sucking, swallowing and breathing
 Efficiency is defined as volume/minute
 Slower flow bottles support both skill and Observer vs. Co‐
Regulator
• Observer is Aware of infant behaviors
• Co‐Regulator is both Aware of behaviors and
Responds to signs of distress with the goal of maintaining or regaining Homeostasis
breathe coordination and physiologic stability
 Pacing supports the suck/swallow breathe coordination and/or the infant’s own internal regulation
Slow Flow Bottle/Nipples
 Many factors affect flow rate
 Most disposable nipples have significant variability in flow rate (poor consistency)
 Tightening the nipple often slows the flow by occluding the air exchange, and may lead to “vacuum build‐up”
 Slower flow rate may help the infant engage suction and have less anterior spillage
 Bottles that eliminate this vacuum build‐up may facilitate feeding skill development
Pados, etal, 2015; Jackman, 2013;
Lau, etal, 2015; Eishima, 1991 © 2007‐2016 Feeding FUNdamentals, LLC Intervention strategies
Clinical Example: Preterm
 Implement intervention strategies to improve skill, efficiency, endurance
 Infants fed with both single‐hole and cross cut nipples.  SKILL and EFFICIENCY
 Slower Flow Bottles
 Positioning
 Pacing
 ENDURANCE
 Behavioral state support
 SUPPORT BREASTFEEDING
Crossover design. When fed with single‐hole nipple units:
 Higher intake (57.5 ml vs. 51.6 ml, p=.011)
 Decreased duration feeding time per meal (11.5 min vs. 20.9 min, p<.001)  Higher efficiency (5.8 ml/min vs. 2.7 ml/min, p<.001)  With single‐hole nipple units  Lower RR (40.8 bpm vs. 44.4 bpm, p=.002)
 SUPPORT PARENTS AS CAREGIVERS
Chang, et al., 2007
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Clinical Example: BPD
 Infants with severe bronchopulmonary dysplasia (n=13) compared to non‐BPD (n=7) demonstrated:
 Lowest sucking pressure
 Lowest sucking frequency
 Shortest sucking burst duration
 Lowest feeding efficiency
 Lowest frequency of swallows during the run  Longest deglutition apnea
 Highest respiratory rate
 Largest decrease in oxygen saturation
Supporting respiratory organization Avoid fluid collecting in the back of the throat
Sidelying
Upright
Mizuno, et al., 2007
Feeding FUNdamentals, LLC (C) 2013
Late Preterms
Positioning
 Feeding difficulties identified in 40.6% of all infants  Determine need to start with a special position born 34‐36 6/7 weeks:
 61% of infants at 34 weeks
 42% of infants at 35 weeks
 35% of infants at 36 weeks
 Latching and poor effort predominant concerns
Medoff‐Cooper, et al., 2012
(sidelying, or upright) based upon the history and stability of the infant
 Begin in cradle hold, or change to cradle hold as tolerated
 Support the motor system during bottle feeding by swaddling
 Bring body, extremities into flexion and midline
 Keep body in alignment
 Hold close to caregiver
© 2007‐2016 Feeding FUNdamentals, LLC © 2007‐2016 Feeding FUNdamentals, LLC Position
Even in Term Infants:
 Should be supportive of midline positioning of arms, legs,  Term infants (n = 15)  Seen at < 1 month and at 2‐4 months postpartum  Improvement in efficiency:
 transferred a similar amount of milk (p = .15) over a shorter duration later in lactation (p = .04)  Suck bursts became longer (p<.001)
 Pauses became shorter (p<.001)
 Vacuum levels decreased (p<.05)
 Oxygen saturation increased (p<.001)
 Heart rate decreased (p<.001) Sakalidis, et al., 2013
neck, head
 Should prevent fluid from collecting in pharynx
 Should encourage close contact with parent
 Elevated Side‐lying appears to be beneficial and does not increase length of stay
 Elevated side‐lying appears to improve oxygenation during feedings
 Elevated head‐tilt position decreases apnea and bradycardia during feeding  Should encourage interaction
Jones, 2008;Clark, 2007;
Jenni, 2007; Park, et al., 2014
© 2007‐2016 Feeding FUNdamentals, LLC 6
Pacing Technique
 Provide external pacing if necessary when baby having difficulty coordinating suck, swallow and breathing
 Two types of pacing:
 Regulated Pacing
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PROACTIVELY provide rhythm for suck/breathe sequence
 Rested Pacing
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For infants who are pacing their suck/breathe sequence but who begin to lose homeostasis across the feeding, REACTIVELY pace through rest breaks
© 2007‐2016 Feeding FUNdamentals, LLC Regulated Pacing
 Facilitates infant’s burst/pause rhythm (3‐5 sucks)
 Gentle shifting of infant and/or bottle (or breast occlusion) to slow or stop flow:
 in central tongue groove
 out of central tongue groove
 removal of bottle
 GOAL: Maintain stability of physiologic, motor and state
Rested Pacing
 Pacing may be provided in response to infant’s fatigue/stress, AS LONG AS THEY HAVE THE SUCK/BREATHE SEQUENCE ORGANIZED
 Brief (1/2 to 2 minute) pauses to allow infant to reorganize
 Very effective with medically compromised infants
© 2007‐2016 Feeding FUNdamentals, LLC Efficiency
 Infants who exhibit suction with pacifier and with appropriate flow rate from bottle will revert to compression‐only sucking (dropping suction component) when flow rate is too fast
 As infants drop suction, they become less efficient and have greater respiratory effort
 Slowing the flow rate helps to establish skill and efficiency Eishima, 1991
Ross & Philbin, 2011
© 2007‐2016 Feeding FUNdamentals, LLC Regulated Pacing Technique
 36 infants – 18 in control, 18 in paced group
 Paced infants demonstrated significant decreases in Bradycardic incidences
 Gains in development of more efficient sucking patterns at discharge
 No change in discharge or average weekly weight gain
Law‐Morstatt, et al., 2003
© 2007‐2016 Feeding FUNdamentals, LLC © 2007‐2016 Feeding FUNdamentals, LLC 7
Support Breastfeeding
 Colostrum is loaded with pre and probiotics and supports growth of gut flora
 Breastmilk is best (gut flora, decreased obesity rates, decreased allergy/immune issues)
 Fresh mother’s milk is the first choice in preterm infant feeding
 Strong efforts should be made to promote lactation
 Breastfeeding is best (provides all of these caregiver contributions; reinforces parental involvement)
 Breastfeeding improves cognitive outcomes
Lennon, 2011
ESPGHAN Committee on Nutrition, 2013
Horta, et al., 2015
© 2007‐2016 Feeding FUNdamentals, LLC Mother’s own milk
 reduces the risk of morbidities in premature infants:  enteral feed intolerance;  nosocomial infection;  necrotizing enterocolitis (NEC);  chronic lung disease (CLD);  retinopathy of prematurity (ROP);  developmental and neurocognitive delay;  and re‐hospitalization after NICU discharge.
 Can be used for oral care to reduce ventilator‐acquired pneumonias
Meier, et al., 2010
© 2007‐2016 Feeding FUNdamentals, LLC Physiologic stability during feeding
 Review of literature
 Infants maintain physiologic stability as early as 27‐28 weeks PMA
 Minimal variation in HR and O2 saturations during breastfeeding; more variation during bottle feeding
 Skin‐to‐skin contact instrumental in transition to breastfeeding
Lucas & Smith, 2015
© 2007‐2016 Feeding FUNdamentals, LLC Breastfeeding and “pacing”
 Most infants do not need pacing with breastfeeding; they are more regulated.
 If an infant is struggling with flow rate, may try a breast shield.
 It may be beneficial to hand express through the first let‐
down to decrease flow rate for first part of feeding
 May try pumping between feedings to decrease volume
 May break seal with thumb every 3‐5 sucks (difficult)
© 2007‐2016 Feeding FUNdamentals, LLC Support Breastfeeding
Breast Shields
 Retrospective cohort (n=66 VLBW infs).
 Positive association between breast milk feedings at  Use of a Breast shield discharge and mothers putting their infants directly to breast in the NICU (P=0.0005).  Duration of breast milk feedings associated with:  mothers putting infant directly to breast (P=0.01)  whether the first oral sucking feeding was at the breast (P=0.01)  gestational age of the first breast‐feeding attempt (P<0.0001).
Pineda, 2011
© 2007‐2016 Feeding FUNdamentals, LLC  Supports latching because it allows the “touch” to be further back in the oral cavity
 Should be sized to both the infant and the mother
 There should be a small space between the end of the mother’s nipple and the end of the crown of the nipple shield.  Direct the nipple shield towards the baby's nose and encourage wide opening of the mouth. As the infant opens his mouth, the shield can be directed towards the roof of the mouth
https://www.breastfeeding.asn.au/bfinfo/nipple‐shields
© 2007‐2016 Feeding FUNdamentals, LLC 8
Supplemental Feeding Systems
with breastfeeding
 May consider for mothers with a low milk supply
 Consider for infants who require a complement of fortified milk
 Put fortified milk into system, and have infant breastfeed while taking in fortified milk using the system
 Consider for infants when a mother is unable to use own milk (especially when it is temporary)
Pre‐ and Post Test Weights
 Not interested in how much infant weighs (=do not strip infant naked)
 Support infant by swaddling during the weighing
 Weigh infant without making changes pre‐ and post‐
feeding
 do not change diaper
 remember if the hat was on…
 Unhook all wires, tubes and weigh with infant
 Weight change in grams = breastmilk intake in mls
Meier, et al., 1990
© 2007‐2016 Feeding FUNdamentals, LLC © 2007‐2016 Feeding FUNdamentals, LLC Cup Feeding
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Used for many years to feed fragile infants
Requires training from a competent, experienced feeder
n=522 preterm infants (32 to 35 weeks GA) Infants randomized to cup versus bottle feeding:
 more likely to be exclusively breastfed at discharge home, 



and
3 months after discharge, and
6 months after discharge
no significant difference for length of hospital stay
no significant difference for time spent feeding, feeding problems, or weight gain in hospital.
Support Breastfeeding
 Colostrum is loaded with pre and probiotics and supports growth of gut flora (Lennon, 2011)
 Breastmilk is best (gut flora, decreased obesity rates, decreased allergy/immune issues)
 Breastfeeding is best (provides all of these caregiver contributions; reinforces parental involvement)
 Infants can often transition from kangaroo mother care to breast exploration earlier than they are ready for bottle feeding
 May need to pump prior to breastfeeding to slow flow until skill is developed  Breastfeeding does not require more energy (Berger, 2009)
Yilmaz, et al., 2014
© 2007‐2016 Feeding FUNdamentals, LLC Supports for Breastfeeding
 Use hospital‐grade breast pumps to effectively empty breasts
Factors influencing breastfeeding post‐discharge
 Kangaroo mother care
 Encourage breast exploration from as early on as infant is stable (kangarooing turns into breast exploration)
 Prenatal education regarding breastfeeding,
 Be Patient!  Perception of providing appropriate volumes (Mothers want to be reassured!)
 Pre‐ and Post‐test weights – ONCE breastfeeding is going fairly well and audible swallows are heard. BE POSITIVE!
 Quantity of breastmilk available,
 Maternal breastfeeding knowledge, Briere, et al., 2014
Lennon, 2011
© 2007‐2016 Feeding FUNdamentals, LLC © 2007‐2016 Feeding FUNdamentals, LLC 9
References
We make a difference!
 Almeida, H., Venancio, S. I., Sanches, M. T., & Onuki, D. (2010). The impact  To the infant:
 By understanding development so that we adjust our expectations
 By supporting organization of physiologic, motor, behavioral states, so that infants can interact and attend to experiences
 By ensuring all experiences are as pleasurable as possible
 To the family:
 By supporting them to be able to nurture their infant
of kangaroo care on exclusive breastfeeding in low birth weight newborns. J Pediatr (Rio J), 86(3), 250‐253.
 Als, H., Gilkerson, L., Duffy, F. H., McAnulty, G. B., Buehler, D. M., Vandenberg, K., et al. (2003). A three‐center, randomized, controlled trial of individualized developmental care for very low birth weight preterm infants: medical, neurodevelopmental, parenting, and caregiving effects. J Dev Behav Pediatr, 24(6), 399‐408.
 Asadollahpour, F., Yadegari, F., Soleimani, F., & Khalesi, N. (2015). The Effects of Non‐Nutritive Sucking and Pre‐Feeding Oral Stimulation on Time to Achieve Independent Oral Feeding for Preterm Infants. Iran J Pediatr, 25(3), e809.
 Berger, I., Weintraub, V., Dollberg, S., Kopolovitz, R., & Mandel, D. (2009). Energy expenditure for breastfeeding and bottle‐feeding preterm infants. Pediatrics, 124(6), e1149‐1152.
References
 Bingham, P. M., Ashikaga, T., & Abbasi, S. (2010). Prospective study of Jake Roberts
non‐nutritive sucking and feeding skills in premature infants. Arch Dis Child Fetal Neonatal Ed, 95(3), F194‐200.
 Briere, C. E., McGrath, J., Cong, X., & Cusson, R. (2014). An integrative review of factors that influence breastfeeding duration for premature infants after NICU hospitalization. J Obstet Gynecol Neonatal Nurs, 43(3), 272‐281.  Chang YJ, Lin CP, Lin YJ, Lin CH. Effects of single‐hole and cross‐cut nipple units on feeding efficiency and physiological parameters in premature infants. J Nurs Res. Sep 2007;15(3):215‐223.
 Clark, L., Kennedy, G., Pring, T., & Hird, M. (2007). Improving bottle feeding in preterm infants: Investigating the elevated sidelying
position. Infant, 3(4), 154‐158.
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References
 Eishima, K. (1991). The analysis of sucking behaviour in newborn infants. 
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Early Hum Dev, 27(3), 163‐173.
ESPGHAN Committee on Nutrition. (2013). Donor Human Milk for Preterm Infants: Current Evidence and Research Directions. J Pediatr
Gastroenterol Nutr, 57(4), 535‐542.
Flacking, R., & Dykes, F. (2013). 'Being in a womb' or 'playing musical chairs': the impact of place and space on infant feeding in NICUs. BMC Pregnancy Childbirth, 13, 179.
Gewolb IH, Vice FL. Abnormalities in the coordination of respiration and swallow in preterm infants with bronchopulmonary dysplasia. Dev Med Child Neurol. Jul 2006;48(7):595‐599.
Gewolb IH, Bosma JF, Reynolds EW, Vice FL. Integration of suck and swallow rhythms during feeding in preterm infants with and without bronchopulmonary dysplasia. Dev Med Child Neurol. May 2003;45(5):344‐348.
References
 Hake‐Brooks, S. J., & Anderson, G. C. (2008). Kangaroo care and breastfeeding of mother‐preterm infant dyads 0‐18 months: a randomized, controlled trial. Neonatal Netw, 27(3), 151‐159.
 Harding C. An evaluation of the benefits of non‐nutritive sucking for premature infants as described in the literature. Arch Dis Child. Aug 2009;94(8):636‐640.
 Heidarzadeh, M., Hosseini, M. B., Ershadmanesh, M., Gholamitabar
Tabari, M., & Khazaee, S. (2013). The Effect of Kangaroo Mother Care (KMC) on Breast Feeding at the Time of NICU Discharge. Iran Red Crescent Med J, 15(4), 302‐306.
 Horta, B. L., Loret de Mola, C., & Victora, C. G. (2015). Breastfeeding and intelligence: a systematic review and meta‐analysis. Acta
Paediatr, 104(467), 14‐19.
References
 Jackman, K. T. (2013). Go with the Flow: Choosing a Feeding System for Infants in the Neonatal Intensive Care Unit and Beyond Based on Flow Performance. Newborn & Infant Nursing Reviews, 13, 31‐34.
 Jenni, O. G., von Siebenthal, K., Wolf, M., Keel, M., Duc, G., & Bucher, H. U. (1997). Effect of nursing in the head elevated tilt position (15 degrees) on the incidence of bradycardic and hypoxemic episodes in preterm infants. Pediatrics, 100(4), 622‐625.
 Jones, K. (2008). The effect of positioning on the transition from tube to oral feeding in preterm infants: A pilot study. Arch Dis Child Fetal Neonatal Ed, 93(Suppl 1), Fa80.
 Kaffashi, F., Scher, M. S., Ludington‐Hoe, S. M., & Loparo, K. A. (2013). An analysis of the kangaroo care intervention using neonatal EEG complexity: a preliminary study. Clin Neurophysiol, 124(2), 238‐
246.
References
 La Orden Izquierdo, E., Salcedo Lobato, E., Cuadrado Perez, I., Herraez
Sanchez, M. S., & Cabanillas Vilaplana, L. (2012). [Delay in the acquisition of sucking‐swallowing‐breathing in the preterm; efects of early stimulation]. Nutr Hosp, 27(4), 1120‐1126.  Lau, C., Fucile, S., & Schanler, R. J. (2015). A self‐paced oral feeding system that enhances preterm infants' oral feeding skills. J Neonatal Nurs, 21(3), 121‐126.
 Law‐Morstatt L, Judd DM, Snyder P, Baier RJ, Dhanireddy R. Pacing as a treatment technique for transitional sucking patterns. J Perinatol. Sep 2003;23(6):483‐488.
 Lennon, M. (2011). Improving In‐Hospital Breastfeeding Management for the Late Preterm Infant. Neonatal Intensive Care, 24(1), 18‐21.
References
 Liu, Y. L., Chen, Y. L., Cheng, I., Lin, M. I., Jow, G. M., & Mu, S. C. (2013). Early oral‐motor management on feeding performance in premature neonates. J Formos Med Assoc, 112(3), 161‐164.  Lucas, R. F., & Smith, R. L. (2015). When is it safe to initiate breastfeeding for preterm infants? Adv Neonatal Care, 15(2), 134‐141.
 Medoff Cooper, B., Holditch‐Davis, D., Verklan, M. T., Fraser‐Askin, D., Lamp, J., Santa‐Donato, A., . . . Onokpise, B. (2012). Newborn Clinical Outcomes of the AWHONN Late Preterm Infant Research‐Based Practice Project. J Obstet Gynecol Neonatal Nurs, 41(6), 774‐785.
 Meier, P. P., Engstrom, J. L., Patel, A. L., Jegier, B. J., & Bruns, N. E. (2010). Improving the use of human milk during and after the NICU stay. Clin
Perinatol, 37(1), 217‐245
References
 Meier, P. P., Lysakowski, T. Y., Engstrom, J. L., Kavanaugh, K. L., & Mangurten, H. H. (1990). The accuracy of test weighing for preterm infants. J Pediatr Gastroenterol Nutr, 10(1), 62‐65.
 Mizuno, K., Nishida, Y., Taki, M., Hibino, S., Murase, M., Sakurai, M., et al. (2007). Infants with bronchopulmonary dysplasia suckle with weak pressures to maintain breathing during feeding. Pediatrics, 120(4), e1035‐1042.
 Nyqvist KH, Anderson GC, Bergman N, et al. Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care. Acta Paediatr. Jun 2010;99(6):820‐826.
 Pados, B. F., Park, J., Thoyre, S. M., Estrem, H., & Nix, W. B. (2015). Milk Flow Rates From Bottle Nipples Used for Feeding Infants Who Are Hospitalized. Am J Speech Lang Pathol, 24(4), 671‐679. 11
References
Park, J., Thoyre, S., Knafl, G. J., Hodges, E. A., & Nix, W. B. (2014). Efficacy of semielevated side‐lying positioning during bottle‐feeding of very preterm infants: a pilot study. J Perinat Neonatal Nurs, 28(1), 69‐79.
Pineda, R. (2011). Direct breast‐feeding in the neonatal intensive care unit: is it important? J Perinatol, 31(8), 540‐545.
Pinelli J, Symington A. Non‐nutritive sucking for promoting physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev. 2005(4):CD001071.
Ross, E. S. and M. K. Philbin (2011). "SOFFI: An evidence‐based method for quality bottle‐feedings with preterm, ill, and fragile infants." Journal of Perinatal and Neonatal Nursing 25(4): 349‐357.
Sakalidis, V. S., McClellan, H. L., Hepworth, A. R., Kent, J. C., Lai, C. T., Hartmann, P. E., & Geddes, D. T. (2012). Oxygen Saturation and Suck‐
Swallow‐Breathe Coordination of Term Infants during Breastfeeding and Feeding from a Teat Releasing Milk Only with Vacuum. Int J Pediatr, E Pub 2012 May 9, 130769. References
 Scher, M. S., Ludington‐Hoe, S., Kaffashi, F., Johnson, M. W., Holditch‐Davis, D., & Loparo, K. A. (2009). Neurophysiologic assessment of brain maturation after an 8‐week trial of skin‐to‐skin contact on preterm infants. Clin Neurophysiol, 120(10), 1812‐1818.
 Yildiz, A., Arikan, D., Gozum, S., Tastekin, A., & Budancamanak, I. (2011). The effect of the odor of breast milk on the time needed for transition from gavage to total oral feeding in preterm infants. J Nurs
Scholarsh, 43(3), 265‐273.
 Yilmaz, G., Caylan, N., Karacan, C. D., Bodur, I., & Gokcay, G. (2014). Effect of Cup Feeding and Bottle Feeding on Breastfeeding in Late Preterm Infants: A Randomized Controlled Study. J Hum Lact, 30(2), 174‐179.
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