Neonatal Feeding Behavior as a Complex

Dynamical System
Eugene C. Goldfield, Ph.D.,1 Jennifer Perez, M.S., CCC-SLP,2 and
Katherine Engstler, M.A., CCC-SLP2

ABSTRACT

The requirements of evidence-based practice in 2017 are

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motivating new theoretical foundations and methodological tools for
characterizing neonatal feeding behavior. Toward that end, this article
offers a complex dynamical systems perspective. A set of critical concepts
from this perspective frames challenges faced by speech-language
pathologists and allied professionals: when to initiate oral feeds, how
to determine the robustness of neonatal breathing during feeding and
appropriate levels of respiratory support, what instrumental assessments
of swallow function to use with preterm neonates, and whether or not to
introduce thickened liquids. In the near future, we can expect vast
amounts of new data to guide evidence-based practice. But unless
practitioners are able to frame these issues in a systems context larger
than the individual child, the availability of “big data” will not be
effectively translated to clinical practice.

KEYWORDS: Dynamical systems, sucking, synergy, emergence

Learning Outcomes: As a result of this activity, the reader will be able to (1) describe how a dynamical
systems perspective may be used to assess when to initiate oral feeding in preterm neonates; (2) define a
synergy, and describe how it informs sucking and respiration behavior; and (3) describe the role of the
caregiver as part of a complex system.

T he interactions between multiple physi- intuitively identify when feeding is “going

ological systems, behavioral dynamics, and so- well” and when it is not, quantifying this gestalt
cial interactions make newborn feeding a characterization of the complexity of feeding is
complex, dynamical system. Although experi- quite challenging. The requirements of evi-
enced caregivers and clinicians are able to dence-based practice in 2017 are motivating

1
Department of Psychiatry, Harvard Medical School, Bos-
ton, Massachusetts; 2Feeding and Swallowing Program,
Boston Children’s Hospital, Boston, Massachusetts.
Address for correspondence: Eugene C. Goldfield, Ph.
D., Boston Children’s Hospital, 300 Longwood Avenue,
Pavilion 159, Boston, MA 02115
(e-mail: eugene.goldfield@childrens.harvard.edu).
Pediatric Dysphagia; Guest Editor, Gilson J. Capilouto,
Ph.D., CCC-SLP, ASHA Fellow.
Semin Speech Lang 2017;38:77–86. Copyright # 2017
by Thieme Medical Publishers, Inc., 333 Seventh Avenue,
New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI: http://dx.doi.org/10.1055/s-0037-1599105.
ISSN 0734-0478.
77
78 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 38, NUMBER 2
new theoretical foundations and methodologi-
cal tools for characterizing not only the anatomy
and physiology of oropharyngeal structures, but
also how they are organized for the swallowing
function.1 The elegant architecture of the hun-
dreds of muscles of the hydrostatic tongue and
the muscles of the pharynx, lungs, and inter-
costals constitute hundreds of controllable de-
grees of freedom. Moreover, the ability of the
pharyngeal anatomy to change its shape for
different functions presents the newborn with
the remarkable challenge of using the same
anatomy in different ways for breathing, swal-
lowing, and vocalizing. To do so requires rapid
transitions in the organization of these muscles
into functional groupings, under the guidance
of exquisitely refined receptive fields. And yet,
most newborns are able to organize their
breathing and vocalizing to cry robustly as a
signal that they are hungry, then reorganize
their breathing to couple with swallowing as
they begin orally feeding, coo contentedly when
sated, and change their breathing pattern when
they fall asleep. Why do some newborns have
such great difficulty in feeding and in making
these transitions between quiet breathing and
swallowing during feeding?
Despite the well-characterized anatomy
and physiology underlying newborn feeding,
as well as the availability of sophisticated imag-
ing and computer-aided measurement of the
timing of swallowing events, practitioners still
do not have adequate foundational theoretical
and mathematical tools for revealing the “hid-
den” information in “big data” for objectively
identifying the empirical basis of their clinical
judgments. The result is that controversies in
practice remain. For prematurely born neo-
nates, when should full oral feedings begin?
Should thickened fluids be used for treatment
of dysphagia? How do different levels of respi-
ratory support influence feeding behavior? This
article offers the view that current approaches to
diagnosis and treatment of feeding problems in
newborns may be overlooking five critical char-
acteristics of feeding as a complex dynamical
system:
1. The “primitive” parts involved in feeding
behavior, traditionally called reflexes or
rhythms, are governed instead by a small
2017
bestiary of underlying “attractors,” each with
a unique signature dynamics revealed in
measurements of neonatal behavior during
sucking, breathing, and swallowing.
2. The nervous system controls the oropharyn-
geal and respiratory anatomy not simply by
activating individual muscles, but rather by
collecting muscles and elastic tissue into
functional groupings, or synergies, so that
adjustments in one part of the system are
automatically compensated in other parts.
The same parts of the system may be used in
different ways for different functions and so
must rapidly assemble for one function (say,
vegetative breathing), dissolve that organi-
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zational pattern, and become reassembled for
another function (say, feeding) while re-
maining stable despite these perturbations
(i.e., remaining robust).
3. Newborns use the mouth to spontaneously
explore the properties of the breast and
milk—their taste, texture, temperature, elas-
ticity—as sensory input for generating at-
tractor dynamics that promote the functional
activity of suckling. Through such active
exploratory behavior during suckling, infor-
mation for regulating milk flow becomes
coupled with the attractor dynamics govern-
ing action, forming a suckling system.
4. Growth, a biomarker of robust health, is an
emergent property of all of the interacting
components that contribute to it and not
predictable from any of the individual com-
ponents alone. As one illustration, obesity
may be an emergent property of body
growth, relative to the timing of introduc-
tion of formula, and of solid foods.
5. The neonate is part of a larger complex
system, a consortium, which includes the
mother, as well as the newborn-host gut
microbiome. The gut microbiome is the
combined genetic material and metabolic
activity of all micro-organisms found in
the gut, including 100 trillion archaea, bac-
teria, microscopic fungi, parasites, and
viruses.2
Addressing these five characteristics of
neonatal feeding behavior as a complex dynam-
ical system—attractor dynamics, functional or-
ganization into synergies, exploratory behavior,

emergence, and consortia membership—may
require a conceptual framework not yet em-
braced by speech-language pathologists treat-
ing dysphagia. This conceptual framework, a
dynamical systems approach to development,1,3
has already had a major impact on other clinical
scientific fields, including physical and occupa-
tional therapy and neurology.4,5 In this article,
we consider how a dynamical systems approach
based upon the preceding five characteristics of
feeding behavior may help to address some of
the controversies faced by speech-language
pathologists in their daily practice of diagnosis
and intervention of neonatal feeding problems.
The other articles in this special issue will
address each of these issues in greater detail.
Here, we frame these issues in a systems
context.
A DYNAMICAL SYSTEMS
APPROACH TO NEWBORN
FEEDING BEHAVIOR:
ATTRACTORS, EXPLORATORY
BEHAVIOR, SYNERGIES,
EMERGENT FUNCTIONS, AND
CONSORTIA
Attractors
Clinical practitioners are quite familiar with the
concept of reflexes,6 a term used to characterize
certain newborn behaviors—sucking, turning
the head toward the breast, and flexing the
arms to bring the hands to the mouth—and
are taught how to elicit and evaluate these
behaviors. At the same time, however, careful
observers of hungry newborns may readily notice
rhythmic mouthing behaviors that are not eli-
cited in any way and may continue spontaneous-
ly, even in sleep. So, is newborn sucking behavior
reflexive or spontaneous? Sucking has both the
organizational integrity of a reflex, and the
tendency to switch from a nonnutritive to nutri-
tive pattern relative to milk supply, and at the
same time, is a spontaneous rhythmic pattern.
With advances in recording and in the mathe-
matical techniques for uncovering hidden pat-
terns in data,7,8 it has become possible to reveal
the two-sided nature of this complex behavior.
From a dynamical systems perspective, sucking
and other rhythmic behaviors that couple to
NEONATAL FEEDING BEHAVIOR/GOLDFIELD ET AL 79
form coordinated patterns, resist perturbation,
and are capable of switching from one stable state
to another are all evidence for underlying attrac-
tors, elementary building blocks, sometimes
called primitives for action.9,10
How is it possible to reveal attractors in
neonatal feeding behavior? One characteristic of
particular relevance to neonatal feeding is the
coordination between sucking and respiration.
Goldfield et al found, for example, that the
frequency of respiration changes dramatically
between quiet breathing compared with breath-
ing during nutritive sucking.11,12 During a quiet
and alert behavioral state, breathing occurs at a
frequency of 1 Hz, with little variability.13
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However, when newborns begin sucking and
swallowing at the breast or from a bottle, the
frequency of breathing increases, and falls into a
stable integer ratio pattern of two sucks for each
breath, or three sucks for every two breaths.
Here, then, the two rhythms become coupled,
and form a coordinated pattern. Coordination
dynamics are also evident in other aspects of
neonatal behavior, including coordination of the
two legs during kicking.14,15 This suggests that
these behaviors may be revealing the underlying
neural and biomechanical primitives contribut-
ing to pattern generating and switching.16
A second characteristic of neonatal sucking
patterns revealing an underlying signature of
attractor dynamics is the rapid switching be-
tween two characteristic patterns seen in nutri-
tive and nonnutritive sucking. To investigate this
question, Goldfield et al conducted experiments
in which the milk supply was abruptly switched
off during nutritive sucking or switched on
during nonnutritive sucking.11,12 With milk
off, newborns used a highly stable 2-Hz pattern
of nonnutritive sucking. However, when milk
was switched on, the pattern abruptly switched to
a slower, more variable 1-Hz pattern of suckling.
In terms of attractor dynamics, the rapid transi-
tion between these two stable states indicates that
sucking is generated by a bi-stable attractor.
Exploratory Behavior
A dynamical systems approach to neonatal
feeding considers behavior at the breast or
bottle in terms of the joint physiological, be-
havioral, and informational regulation of the
80 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 38, NUMBER 2
newborn’s behavior. At the breast, nature pro-
vides newborns with an exquisitely tuned organ
for feeding. Newborns actively look, touch, and
taste breast milk during breast-feeding. The
context of breast-feeding makes information
available for the guided discovery of how to
regulate sucking and swallowing milk while
maintaining vegetative breathing. Indeed, dur-
ing bottle-feeding, the challenge for a caregiver
is to try to emulate nature by observing the
neonate to make some of the same kinds of
postural and timing adjustments apparent dur-
ing breast-feeding. Clinicians and engineers
have sought to use computer-controlled devices
to emulate the breast, but the realization of such
a device still remains in the future. In current
practice, information provided to the caregiver
or clinician is referred to as cues, but a more
theoretically guided approach to how neonates
explore available information to regulate their
behavior may be found in the work of James and
Eleanor Gibson (and see accounts of this ap-
proach in numerous reviews, such as Adolph
and Kretch17). In the Gibsonian view, infor-
mation in a structured environment is revealed
through looking, listening, feeling, and tast-
ing—all active processes of information pickup.
Synergies and Multifunctionality
From a dynamical systems perspective, nature
may build the complex behaviors of feeding and
speaking by coupling together self-sustaining
primitives to form a synergy, a functional unit in
which multiple degrees of freedom behave as a
single functional unit, so that perturbations to
some components are responded to by the
entire unit.18 An illustration of the adaptation
of an entire ensemble of articulators to a
perturbation of just a part comes from a classic
study by Kelso and colleagues.19 They applied
brief perturbations to the jaw of a speaker
repeating a single-syllable utterance. In the
case of the syllable /bab/, the jaw perturbation
was applied as it moved upward to close the
vocal tract for producing the final phoneme /b/.
Kelso et al found that within 15 to 30 milli-
seconds, there was also an adjustment of the
upper and lower lips, indicating that a collection
of articulators forming a synergy with the jaw,
and not the jaw alone, responded to the pertur-
2017
bation.19 This kind of experiment reveals the
signature characteristic of a synergy: it is a
cooperative organization of weakly coupled
parts. What does the nervous system contribute
to the formation and dissolution of synergies?
A dramatic demonstration that muscle
synergies are encoded in the nervous system
comes from a series of studies by Overduin et
al,20,21 who applied long-duration electrical
intracortical microstimulation (ICMS) to mo-
tor areas in two awake monkeys and simulta-
neously recorded muscle electromyography
(EMG) and finger movements. Overduin et
al found that ICMS drives the hand and digits
toward particular postures at each stimulation
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site.20 Moreover, the evoked EMG patterns
resembled muscle coactivations seen in tempo-
rally complex behaviors, such as reach and
grasp.22,23 As further evidence for cortical en-
coding of synergies, Overduin et al examined
whether the muscle synergies evoked during
ICMS were similarly encoded during purely
voluntary behaviors.21 At each microstimula-
tion site, they determined that the synergy most
strongly evoked among those extracted from
muscle patterns matched the synergy most
strongly encoded during voluntary behavior
more often than expected by chance. At the
same time, however, our nervous systems are
embodied: our brain and spinal cord have
evolved to leverage the biomechanical proper-
ties of the body, such as the shapes possible by
our hydrostatic tongue, the elastic properties of
our lips, and the power of our jaw muscles, to
perform the distinctive functions of eating and
speaking. Are there synergies in neonatal feed-
ing behavior? An illustration of how the ner-
vous system rapidly assembles functionally
specific synergies for feeding is in the transfor-
mation of the oral anatomy into a macroscopic
functional device, a pumper.1
Emergent Functions: Pumping
Biological pumps, such as the heart, are a type of
positive displacement pump. Such pumps (1)
move and accumulate successive boluses of fluid
into a confined space, (2) reduce the space
enclosing the fluid to force it to leave by a
specific outlet, and (3) create a pressure differ-
ence that moves a volume.24 The cooperative

organization of the tongue and pharynx may
also serve the function of a positive displace-
ment pump. However, unlike the heart, a pump
dedicated to circulating blood, a pump for
ingesting liquid and solid nutrients must be
rapidly assembled and dissolved to allow the
pharynx to switch between the multiple func-
tions of deglutition, vegetative breathing, and
speaking. How do the tongue and pharynx act
together to become a pumper during neonatal
feeding? The familiar pattern of neonatal suck-
ling may be thought of as the formation and
dissolution of a pumper for deglutition: the
coordination between oral, labial, mandibular,
and lingual-pharyngeal muscles draws milk into
the mouth, seals the lips around the breast
nipple and areola, and forces accumulated
milk boluses into the pharyngeal space, increas-
ing the potential energy of the elastic forces of
the soft tissue until the muscular event of the
pharyngeal swallow.1 Like a physical pump, this
biological pump is most effective at particular
combinations of pressure and volume.24 This
lawful relation between pressure and volume
may be a clinically significant index of swallows
but is not conventionally measured in clinical
practice.
The newborn’s feeding behavior is also
dependent on the lungs, as well as on a large
group of muscles of the chest and abdomen, to
act synergistically as a respiratory pump. Suc-
cessful feeding requires that the shaping of the
tongue relative to the functional anatomy of the
pharynx creates particular patterns of constric-
tion that act functionally as a set of valves for
regulating the flow of fluid, relative to the flow
of air for vegetative breathing. Against the
continual backdrop of the cyclical pattern of
the respiratory pump, muscle groups constrict
the entry to the nasopharyngeal passage and
epiglottis and through changes in pressure force
air from the lungs through openings that define
the airway.25 This is accomplished through the
cooperative activations of the genioglossus and
palatal elevator and by the palatoglossus and
palatopharyngeus muscles and the posterior
cricoarytenoid.26 In preparation for a swallow,
and for deglutition proper, a different set of
anatomical constrictions and openings define a
pathway for fluid that excludes the bolus from
the airway as it is forcefully pumped through the
NEONATAL FEEDING BEHAVIOR/GOLDFIELD ET AL 81
pharynx on its journey to the upper esophageal
sphincter. Deglutition proper involves muscles
controlling retrusion and protrusion of the
tongue, contraction of palatal muscles, vocal
cord adduction, and contraction of the pharyn-
geal constrictors.27 Neonatal feeding, then, may
be made possible by the weak coupling of
respiratory and suck-swallowing attractors,
and dysphagia may be a disorder of synergy
formation and dissolution.
Consortia
A dynamical systems approach places particular
emphasis on the newborn as part of a consor-
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tium, which includes the mother and the new-
born-host gut microbiome. Within this
consortium, there are maternal offspring ex-
changes of microbiota and nutrients provided
during breast-feeding. There is stepwise colo-
nization of the neonatal gut at birth (delivery),
during breast-feeding, and in contact with the
environment.28 Breast milk is a source of pro-
teins, maternal bacteria, and nutrients that
contribute to establishment of the gut micro-
biome and the immune system.29 A critical
implication of considering the newborn as a
member of a host-microbiome consortium is
that the individual nutritional and physical
health of the neonate emerges during a long
period of development of host-microbiome and
caregiving environment. Foodstuffs and other
ingested substances shape the proportional re-
presentation of micro-organisms present in the
neonatal gut microbiome and perturbations of
the microbiome may influence neonatal nutri-
tion and health.30
HOW COMPLEX DYNAMICAL
SYSTEMS INFORM NEONATAL
FEEDING BEHAVIOR
The following sections consider how a dynam-
ical systems perspective may reframe four ques-
tions about neonatal feeding faced by
practitioners at each bedside visit: when to
initiate oral feeds, how to determine the ro-
bustness of neonatal breathing during feeding
and appropriate levels of respiratory support,
instrumental assessments of swallow function in
preterm newborns, and whether or not to
82 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 38, NUMBER 2
introduce thickened liquids. In each case, the
concepts from a dynamical systems perspective
place individual behaviors in a broader context.
When to Initiate Oral Feeds
In the decades since the 1997 articles on
neonatal feeding that appeared in this journal,
the controversy over when to initiate oral feeds
has been informed by a greater appreciation for
feeding complexity (i.e., an expanding of the
range of variables that may be used to make
diagnostic judgments). Rather than simply fo-
cusing on gestational age or on the expected age
at which coordination between sucking and
breathing emerges,31 evidence-based practice
is now turning to considerations of the new-
born’s signs of readiness to initiate oral feeding
such as level of alertness, state regulation,
demonstration of hunger “cues,” and the extent
to which the newborn requires respiratory sup-
port (see Shaker, this issue).32–34
Earlier diagnostic assessments focused on
sucking and oral motor function, such as the
Neonatal Oral Motor Assessment Scale,35 to
characterize neonatal feeding. When consid-
ering feeding in a dynamical systems ap-
proach, oral motor function is only a small
component of the larger decision-making
process in initiating oral feeding. Healthy
preterm newborns may be able to successfully
initiate oral feedings earlier and achieve full
oral feeding faster,36 and a “term sucking
pattern” is not necessarily required for suc-
cessful oral feeding.37 Conversely, preterm
newborns with more complicated courses
and higher neonatal morbidity may require
additional time before they are appropriate to
consider for initiation of oral feeding.38
When sucking alone is assessed in deter-
mining feeding readiness, the synergistic nature
of oral feeding and the intricate requirements of
coordination between sucking, swallowing, and
breathing are not taken into account. When
viewed through a dynamical systems model, on
the other hand, the neonate’s ability to feed
successfully is assessed based on his or her
physiologic stability, state regulation, respira-
tory patterns, and attention/interaction, in ad-
dition to his or her ability to suck.39 There are
multiple subsystems involved in the feeding
2017
process that mature convergently, but not nec-
essarily synchronously.40 Sucking and swallow-
ing are a highly linked and softly assembled
synergy. Modifications to the kinematics of
sucking enable greater stability within the
physiology of the pharyngeal swallow, facilitat-
ing safe bolus passage.41 Providing small
amounts of breast milk or formula on a pacifier
or finger promotes exploration of milk or
formula taste, a means for establishing infor-
mational coupling to guide sucking.42
Consistent with a dynamical systems
view, there are now subjective diagnostic
assessment tools that describe physiological
and behavioral parameters of “infant-driven,”
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or responsive feeding in determining readiness
to initiate oral feeding. Among these tools are
the Early Feeding Skills Assessment, a check-
list for assessing not only newborn readiness
for and tolerance of oral feedings, but also for
assessing specific feeding skills, such as re-
maining engaged in feeding, coordinating
swallowing and breathing, and maintaining
physiologic stability.43 Another is the Support
of Oral Feeding for Fragile Infants, an assess-
ment that examines feeding behavior rather
than the amount of food ingested.44 These
two approaches to determining feeding readi-
ness are part of the current trend toward
establishing in the neonatal intensive care
unit (NICU) a “culture of feeding” (see
Shaker, Part II, this issue).32,45
Oral Feeds and Level of Respiratory
Support: The Role of Robustness
Another major outcome of the current appre-
ciation for the synergy between sucking, swal-
lowing, and breathing during oral feedings is an
attempt to address questions that clinicians may
have regarding appropriate feedings at different
levels of neonatal respiratory support while in
the NICU (see Gross and Trapani-Hanase-
wych, this issue).46 These questions include
whether oral feeds should be initiated during
the period of respiratory support with continu-
ous positive airway pressure (CPAP) or high-
flow nasal cannula (HFNC). Here, we offer a
concept from dynamics, called robustness to
perturbation, as a potential way of helping
clinicians to decide whether or when to initiate

oral feedings while newborns are being sup-
ported by CPAP or HFNC.
The robustness of a complex system is an
indication of its ability to maintain functionality
despite internal and external perturbations. As
one illustration, neural circuits are robust be-
cause they maintain target performance despite
ongoing neuron channel and receptor turn-
over.47 In the context of attractor dynamics,
robustness refers to the way that a system may
either return to its current attractor or move to a
new one that maintains a system’s functions.
Consider the respiratory pattern of a newborn
during quiet sleep, apparently governed by a
limit-cycle attractor with a characteristic signa-
ture of 1 Hz. Internal perturbations of the
respiratory cycle during quiet sleep include
natural fluctuations in neural excitation, includ-
ing muscle “twitches.”48 External perturbations
of breathing include swallowing in response to
accumulations of saliva, loud sounds, or care-
giver postural adjustments. Preterm newborns
who experience apneic breathing may be more
susceptible to both internal and external per-
turbations and have particular difficulty in
adapting their breathing to deglutition. In other
words, compared with term newborns, the
breathing patterns of many premature neonates
are less robust.
Clinical interventions to support respira-
tion of neonates in intensive care may also
influence the robustness to deglutition pertur-
bations during introduction of oral feedings.
These interventions include nasal CPAP, or
nCPAP, and high-flow oxygen via nasal can-
nula (HFO2-NC). HFO2-NC is defined as
small, thin tapered nasal tubes that deliver
oxygen or blended oxygen/air at gas flows of
more than 1 L/min.49 Oxygen delivered by
HFNC is often heated and humidified. The
goal of HFNC is to wash out nasopharyngeal
dead space and increase pharyngeal pressure to
reduce work of breathing.50
When considering if it is appropriate to
initiate oral feeding with newborns in the
NICU who require nCPAP or HFO2-NC
for respiratory support, there are several factors
that must be taken into consideration. The first
question to be asked is why the neonate may
require this level of respiratory support, includ-
ing the newborn’s respiratory status and base-
NEONATAL FEEDING BEHAVIOR/GOLDFIELD ET AL 83
line respiratory disease, considering that flow
rate required may serve as a proxy for severity of
illness. Second is the manner by which in-
creased pressure force from nCPAP or
HFO2-NC may impact (1) swallow function,
(2) airway protection from above, and (3) risk of
bolus misdirection resulting in aspiration.51
Because the majority of newborns who aspirate
during the swallow do so silently,52 to reliably
assess the impact of HFO2-NC or nCPAP on
swallow function, instrumental assessment
would be indicated. Conversely, it is also worth
considering if the neonate’s lung capacity may
be improved on HFO2-NC or nCPAP, may
make the newborn better able to tolerate respi-
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ratory suppression during the swallow, and, if
his or her work of breathing is improved,
whether sucking-swallowing-breathing coordi-
nation may also be improved.
Use of Instrumental Swallowing
Assessments
Given the increased risk of silent aspiration in
newborns who aspirate,52 instrumental swal-
lowing assessments, such as the videofluoro-
scopic swallow study (VFSS) or fiberoptic
endoscopic evaluation of swallowing (FEES),
allow for further definition of physiological
swallow function (see Arvedson and Lefton-
Greif, this issue).53 The VFSS examines swal-
low function in all phases of neonatal swallow-
ing, providing rich information for an
assessment of feeding as a complex, dynamical
system. However, the use of ionizing radiation
and thickening agents for assessment make the
use of VFSS in newborns controversial. Issues
include: (1) liquids tested (i.e., barium) during
VFSS may not match the prescribed liquids in
terms of viscosity,54,55 and (2) the amount of
radiation exposure during VFSS to a preterm or
term newborn is not insignificant. Benefits of
using FEES versus VFSS include the ability to
assess breast-feeding in a more natural setting/
position and no exposure to radiation during
FEES assessment. However, FEES provides a
limited view of the swallow with whiteout
during airway closure, which may make it
difficult to capture aspiration during the swal-
low, in particular with consecutive sucking and
swallowing bursts.56
84 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 38, NUMBER 2
Oral Feedings and Consortia
If a newborn exhibits oropharyngeal dysphagia
on videofluoroscopy that does not improve with
the use of therapeutic feeding interventions such
as slow flow nipples, side-lying position, and
pacing, then thickened liquids may be consid-
ered a treatment option. The use of thickened
liquids in pediatrics to treat dysphagia, and
particularly with neonates, remains controver-
sial. A new direction for evaluating the potential
negative effects of thickening agents is to iden-
tify their effects on the community structure of
the neonatal gut microbiome.57 In this approach,
deviations from normal microbiota development
may be used as a measure of risk assessment for
disease, such as necrotizing enterocolitis (NEC).
In the first postnatal week, the full-term neona-
tal gut microbiome is primarily colonized by
members of the Actinobacteria, Proteobacteria,
Bacteroidetes, and to a lesser extent Firmi-
cutes.58 By contrast, the gut microbiome of
newborns weighing less than 1,200 g is domi-
nated by Firmicutes and Tenericutes. Postnatal
nutrition plays a fundamental role in the succes-
sion of bacterial colonization: healthy breast-fed
newborns receive a mix of nutrients, bacteria,
and oligosaccharides that are believed to prevent
the attack of enteropathogens.59 In addition to
this altered microbial diversity in the gut micro-
biome, premature newborns are immunode-
ficient, predisposing them to invasion by
pathogens that may lead to disease processes
such as NEC.60 It is this context within which
future research may fruitfully determine the
association between thickening agents and
NEC.
CONCLUSIONS
A fundamental and daunting task of speech-
language pathologists and other members of the
feeding team is to diagnose why a newborn is
not eating and gaining weight, and to imple-
ment therapies that promote improved health.
Our hope is that the systems approach pre-
sented here may (1) stimulate an appreciation of
a perspective that includes the rich context of
the newborn and caregiver, and (2) modify
practice in a way that reflects advances in
what we now know about the multiple compo-
nents of the newborn as part of a complex
2017
dynamical system. In the near future, we can
expect vast amounts of new data on interactions
between developing neonate, microbiome,
caregiver, and environment to guide evidence-
based practice. But unless practitioners are able
to integrate these “big data” into their daily
decision making, progress in therapeutic inter-
ventions will not be effectively translated to the
clinic.
DISCLOSURES
Eugene C. Goldfield receives salary from
Boston Children’s Hospital and from the
Wyss Institute.
Downloaded by: University of Texas at Dallas. Copyrighted material.
Jennifer Perez receives a salary from Boston
Children’s Hospital.
Katherine Engstler receives a salary from
Boston Children’s Hospital.
ACKNOWLEDGMENT
The writing of this manuscript was supported in
part by the Wyss Institute, and BCH IDDRC,
1U54HD090255.
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