Evidence-based Interventions for Breast and Bottle Feeding in the Neonatal Intensive Care Unit

Successful neonatal nipple feeding results when there are sufficient and Appropriate
intrauterine experiences, Physiologic maturation and the environmental demand for nursing At bottle or
breast.* Continuity of fetal and infant development culminates typically in the infant’s capability at birth
to respond to being placed at the breast or bottle nipple with sucking and swallowing. As infants Mature
typically they modify the biomechanics of sucking to support their growth by increasing their rate of
intake per feeding time and amount of intake overall. The rhythmic alternation of
expression/compression and Suction characterizes sucking in the full-term infant.

Failure to acquire adequate sucking is seen in some healthy preterm infants: infants with
medical issues that include cardiac, gastrointestinal and pulmonary disorders; infants with genetic and
congenital syndromes that affect structure and function of the upper airway; and infants with neurologic
disorders including primary neuromuscular dysfunction and seizures. The presence of this early
dysphagia may be defined as failure to develop the age-expected capability for (1) ingestion of oral
secretions and/or (2) adequate nutritional intake to sustain growth and hydration with satisfactory
airway protection and rate of intake. The magnitude of the deficiencies in these features may be used as
a determination of severity of dysphagia.

The purpose of this article is to review the evidence-based approaches to the development and
use of assessment tools for nipple feeding, and interventions that promote acquisition and maturation
of sucking behaviors for breast and bottle-feeding. Although the focus is literature published in the past
10 years, references include earlier publications in instances where more recent work is unavailable and
when the findings are relevant to this discussion.

ASSESSMENT

The research base for assessment includes (1) validity, interrater reliability, and predictive
capabilities for specific, assessment strategies, and (2) delineation of normal expectations for sucking
and related physiology to which patients can be compared. Several clinical assessment tools and
protocols that are practical and accessible measure oral sensorimotor patterns for breast and bottle
feeding, However, standardization and validation for many of these assessments are sparse.
Assessments may be developed to differentiate normal from abnormal patterns for the intended
measure(s), to detect progress or regression, to predict the likelihood of specific immediate or long-term
outcomes, and to indicate specific intervention strategies for specific physiologic abnormalities or
functional difficulties.

Clinical Assessment

The clinical assessment for feeding and swallowing in infants may include (1) medical and
developmental history including feeding issues and family concerns; (2) a physical evaluation of anatomy
of mouth, face, and upper body; postural control; movement behaviors; oral and pharyngeal reflexes;
infant state and related behavior; vocal quality as an indicator of vocal-fold function; oral postural
control as an indicator of stability of oral structures and nasal airway patency; swallowing of saliva, and
non-nutritive sucking; and (3) observation of oral feeding with focus on posture and movement,
respiratory rate and sounds; sucking, swallowing, and breathing coordination, sucking rhythm, rate, and
amount of intake; endurance; pre- and postfeeding heart rate and respiratory rate; autonomic stress
cues associated with feeding; and issues related to the mother and infant interactions—a special
concern for breast feeding.

There are several, published clinical assessments for young infants that consider multiple
aspects of the clinical feeding and swallowing evaluation. These tools consist of systematic assessment
forms and written instructions for their use. The forms include history, physical examination, and
observation of Nutritive sucking. The Clinical Feeding Evaluation of Infants (CFE) is a comprehensive
Model for clinical assessment of breast and Bottle-feeding With 4 rationale for inclusion of each set of
Observations. Other assessment models have been published by Arvedson and Brodsky, Fraker and
Walbert, and Swigert, Interrater reliability, validity, and the effectiveness of using these models and
forms to improve Outcomes have yet to be determined However, extensive clinical practice has resulted
in expert Opinion and acceptable professional standards to which the clinician can refer for selecting
appropriate observations and interpreting the findings

Clinical assessment has been aided by the use of tests and forms that Provide systematic
observation of sucking behaviors. These assessments typically address underlying competencies for
sucking and functional outcomes. The premise underlying these tools is that the infant’s capabilities vary
from feeding to feeding and day to day, thereby warranting a systematic method for making
observations at each feeding, or, at the least, periodically during the course of acquiring and improving
oral feeding.

An evidence-based approach was taken by Lau and colleagues to develop a five-stage scale for
maturation of sucking in preterm and term infants. The scale resulted from a study of the
developmental sequence for acquisition of the expression and compression, as well as the suction
components in nutritive sucking in preterm and term infants. The stages were characterized by the
appearance and progressive changes in expression and suction and rhythmic Interaction between
expression and suction. Positive correlations occurred among the five stages of maturation on the scale
and the number of daily oral feedings and amount and rate of intake.

Pickler and colleagues studied preterm infants for 2 to 3 weeks following their first oral feeding
at 32 weeks postmenstrual age (PMA). They found that the number of bottle feedings taken by infants,
irrespective of success at those feedings, and the number of sucks in the first burst of sucking at the
start of a feeding predicted overall success in the current feeding. Those factors plus behavioral state at
the outset of the feeding, Predicted the rate of intake and the amount of intake relative to the
prescribed amount. Although no specific assessment tool Was Presented, the authors concluded that
the number of sucks in the first burst and behavioral State activity be considered when making the
determination of whether to continue with an Oral feeding and when to predict its outcome. Although
the implication is to maximize each infant’s Opportunities for feeding, it is important that oral feeding
be discontinued when no sucking occurs for 2 minutes, or there are signs of difficulty such as oxygen
desaturation, break-up bradycardia, apnea, or loss of muscle tone.

The Neonatal Oral Motor Assessment Scale (NOMAS) was standardized for assessing bottle-
feeding in preterm infants from birth to 3-months old. The NOMAS uses checklists that describe normal,
disorganized, and dysfunctional jaw and tongue movements during nutritive sucking to differentiate
between efficient and inefficient feeders. Premji and colleagues developed an evidence-referenced form
for observing breast or bottle-feeding and an accompanying five-stage scale for the progression from
pre-oral stimulation to full-oral feeding. Their Infant Feeding Assessment Tool prompts the clinician to
observe infant engagement prior to accepting the nipple, sucking characteristics, characteristics of
sucking difficulties, interventions used to improve sucking, and outcomes achieved for the individual
feeding. Thoyre and colleagues described the Early Feeding Skills Assessment for Preterm Infants as an
evidence-referenced checklist for systematic observation of breast or bottle-feeding. Thirty six items are
clustered into the following categories: an infant’s oral-feeding readiness, ability to remain engaged in
feeding, ability to organize oral-motor functioning, ability to coordinate swallowing and breathing,
ability to maintain physiologic stability, and oral feeding recovery. Both the Infant Feeding Assessment
Tool and the Early Feeding Skills Assessment provide intervention options for infant deficiencies. The
Feeding Flow Sheet charts feeding observations during nipple feeding that include the infant’s
physiologic tolerance for oral feeding, task components, supports needed, and quantity of intake.

Tools for systematic observations of breast feeding include the Systematic Assessment of the
Infant at Breast (SAIB), the Preterm Infant Breast-feeding Behavior Scale (PIBBS), and the Breastfeeding
Evaluation. The SAIB is organized into categories of alignment, areolar grasp, areolar compression, and
audible swallowing. The PIBBS is a parental report scale with notations for the task components of
sucking that include letdown, rooting, amount of breast in mouth, latching, suckling bursts, swallowing,
and time factors. The Breastfeeding Evaluation is a guide used to identify when lactation support would
be a benefit. It contains expectations for the task components of sucking plus intake, output, and weight
gain.

Instrumental Assessment
Instrumental strategies used most frequently to assess nipple feeding in the infant with
suspected dysphagia are the videofluoroscopy swallow study (VFSS), and fiberoptic endoscopic
evaluation of swallowing (FEES). The VFSS delineates both biomechanics of all phases of the swallow
during bolus transport. Furthermore, it provides the opportunity to probe the therapeutic benefit for
initiation of swallowing and airway protection by modifying bolus viscosity, nipple selection, cup feeding,
and postural changes. The FEES is used in early infancy primarily for viewing anatomy of the soft palate,
pharynx, and larynx, and initiation and completion of swallows of saliva and nipple feeding. However,
FEES may be less successful in viewing the sequence of swallows seen in nipple feeding than the isolated
swallows seen in the transition feeding of older infants.

INTERVENTION
Varied therapeutic interventions used by speech-language pathologists (SLPs) to improve nutritive
sucking for breast and bottlefeeding include pre-nipple feeding strategies such as oral stimulation and
non-nutritive sucking. Modifications used for nutritive sucking include nipple selection, positioning, and
assistance during nipple feeding, pacing, and altering feeding schedules. The SLP in the NICU needs to
understand the physiology of breast and bottle-feeding, appreciate the importance of breastfeeding in
the mother–infant relationship, and in collaboration with the lactation consultant, provide strategies for
promoting breastfeeding. Oral Stimulation Oral stimulation refers to various nonfeeding oral
experiences that are provided to the infant with the aim of improving outcomes for oral feeding.
Beneficial effects of oral stimulation on the oral-feeding performance of preterm infants have been
reported. Gaebler and Hanzlik demonstrated that preterm infants receiving peri- and intraoral
stimulation just before oral feedings scored better on the NOMAS, had greater weight gain, and fewer
days of hospitalization. Fucile and colleagues provided an oral stimulation program before the
introduction of oral feeding to preterm infants delivered between 26- and 29-weeks gestational age
(GA). Oral feeding was attained significantly earlier in the experimental group than in the control group,
and the overall intake and rate of milk transfer were significantly greater. However, there was no
difference in length of hospital stay between the two groups. The details of the oral stimulation program
including purpose, the oral structures targeted, the stimulation regimen, and frequency and duration of
treatment were described. Non-nutritive sucking (NNS) is another prefeeding stimulation technique
commonly used to promote more efficient nutritive nipple feeding. NNS behavior can be elicited in the
preterm infant as early as 27 weeks gestation.28 It is characterized by organized periods of rapid sucking
separated by brief periods of rest, in contrast to nutritive sucking which is slower and almost continuous
in nature. The Cochrane Review of Randomized Trials found NNS to be associated with reduction in
duration of hospitalization. But, contrary to results reported by Fucile and colleagues, weight gain and
oxygen saturation were not affected significantly. A shorter transition time from tube to bottle feeding
and improved feeding performance occurred with use of NNS prior to introduction of oral feeding. There
were no harmful effects reported with use of NNS.

NNS at the breast has been shown to improve transition to breastfeeding and be associated with
longer breastfeeding duration per feeding session. Infants were observed to root, latch, and have
effective areolar grasp as early as 28-weeks GA when they had maximal exposure time to the breast.32
Infants responded on the first occasion of contact to the mother’s breast with rooting and sucking
behavior regardless of birth GA or postmenstrual age. Nutritive sucking characterized by repeated bursts
of more than 10 sucks emerged at 30-weeks GA and maximum bursts of more than 30 sucks occurred at
32-weeks GA. These findings suggest that once an infant has been extubated, the clinician should
establish a plan with the mother to promote several periods each day of NNS that will prepare the infant
for the transition to breastfeeding. Spatz33 proposed 10 steps for promoting and protecting
breastfeeding for vulnerable infants that incorporate guidelines from the United Nations Children’s Fund
Baby-Friendly Hospital Initiative and the American Academy of Pediatrics. These steps include:

1. Providing parents with information necessary to make an informed decision to breastfeed

2. Assisting the mother to establish and maintain a milk supply

3. Ensuring correct breast milk management (storage and handling techniques)

4. Developing procedures and approaches to feeding breast milk to the infant

5. Providing skin-to-skin care (kangaroo care)

6. Providing opportunities for NNS at the breast

7. Managing the transition to the breast

8. Measuring milk transfer

9. Preparing the infant and the family for hospital discharge

10. Providing appropriate follow-up care

The SLP may be particularly interested in promoting NNS at the breast. The mother uses an electric
pump to empty her breast just prior to the infant’s gavage feeding time. The infant is positioned skin-to-
skin at the breast and the mother manually expresses drops of milk onto the infant’s lips.

Oral-Feeding Strategies
Strategies for improving nutritive sucking during the oral feeding include nipple selection, positioning,
cheek and chin support, pacing, and feeding schedules. Although some of these strategies have been
subjected to experimental study, others continue to be used based on expert opinion and clinical
experience.

NIPPLE SELECTION
Considerable debate has occurred regarding the best nipples to enhance the bottle-feeding
performance of preterm infants. Nipple characteristics that can influence fluid flow are the shape or
material of the nipple and size of the nipple hole—with size of hole playing the larger role. Clinicians and
nurses rely on personal opinion for choosing nipples. However, there is little evidence to support use of
a specific type of nipple for enhancing oral-feeding performance in preterm infants. Scheel and
colleagues37 studied the effectiveness of nipple selection to enhance infant-sucking skills and to
improve the bottle-feeding performance of very lowbirth-weight (VLBW) infants.34 Sucking
performance was monitored using three different nipples offered in randomized order within a 24-hour
period when the infants were taking 1 to 2 oral feedings per day and again when they were taking 6 to 8
feedings per day. Three nipples commonly used in the United States were evaluated: nipple A (Similac
Premature Nipple; Ross Laboratories, Columbus, OH, nipple B (Enfamil Premature Nipple; Mead Johnson
& Co., Evansville, IN) and nipple C (Similac Infant Nipple; Ross Laboratories, Columbus, OH). Rate of milk
transfer (milliliters per minute [mL/min]) was the primary outcome measure. None of the three nipples
enhanced bottle feeding more effectively than the others. At both periods, the infants demonstrated a
similar rate of milk transfer with each of the nipples. However, stage of sucking, suction amplitude, and
duration of the generated suction were significantly different between nipples when the infants were
taking 1 to 2 oral feedings per day, but not when they were taking 6 to 8 oral feedings per day. The
authors concluded that caregivers should be more concerned with monitoring the coordination of suck–
swallow–breathe than with the selection of bottle nipples.

POSITIONING

Proper positioning of the infant during bottlefeeding is thought to be critical for promoting safe and
efficient sucking. In addition, developmentally appropriate positioning during the NICU stay is important
to avoid neck and shoulder retraction, which can interfere with feeding.35 However, despite the
importance attributed to positioning, to our knowledge it has not been studied, and recommendations
continue to be based on expert opinion and clinical experience. Jones and colleagues35 recommended
that the infant’s body should be slightly flexed with the chin tucked during feedings. The arms and
shoulders should be in a forward position. Although there is a wide variation in the normal postural
muscle tone that will support feeding, there should be a balance of function between flexor and
extensor muscle groups, movements should be smooth and well modulated, and there should be an
appropriate amount of movement.10 Wolf and Glass10 described the optimal feeding position as flexion
with the shoulders symmetric and forward, and arms flexed toward midline. They described a neutral
anteroposterior alignment of the head and neck, although they acknowledged that slight flexion or
extension may have therapeutic benefit in some cases. The alignment of the head and neck to the trunk
is a key component of the feeding position. Although slight modifications may prove to be therapeutic
for an infant, Wolf and Glass cautioned that improper alignment may be a major contributor to feeding
dysfunction. Arvedson and Brodsky3 described the appropriate position for nipple feeding as semi-
reclined with a neutral head and neck posture, and flexion at the hips and knees. They provided a visual
model for proper positioning with photograph and figures. Aucott and colleagues29 cautioned that the
infant’s head should be in line with the body as too much neck extension or neck flexion may interfere
with breathing. Overall, proper positioning supports physiologic stability. The team approach, including
pediatric physical and occupational therapists, is valuable for achieving optimum positioning for safe and
efficient feeding.

CHEEK AND CHIN SUPPORT

Einarsson-Backes and colleagues36 demonstrated that supporting the infants cheeks and chin during
nipple feeding increased intake volume in preterm infants. Jaw support is another strategy used to
stabilize the jaw while feeding the infant with generalized hypotonia. This technique is used when the
infant exhibits jaw shifting (side-to-side or forward movement) during bottle-feeding. Jaw stability may
be enhanced by placing the middle finger under the chin and the index finger between the chin and
lower lip.3

EXTERNAL PACING

External pacing is a strategy whereby the feeder assists the infant in appropriately interspersing breaths
during sucking bursts by interrupting the liquid flow.10 Law-Morstatt and colleagues37 studied a paced
feeding protocol in preterm infants with respiratory illness to determine if the strategy would increase
efficiency of sucking and weight gain, decrease incidence of bradycardia during feeding, and shorten
length of hospital stay. These infants were identified with a ‘‘transitional sucking pattern’’ that is
characterized by incoordination of sucking and swallowing with respiration, 6 to 10 sucks and swallows
per burst, and arrhythmic breathing occurring primarily during burst pauses. 38 Thirty-six preterm
infants were enrolled in a nonrandomized clinical trial conducted in the NICU. The first 18 infants were
bottle-fed using traditional strategies. Prior to treating the second group of 18 infants, the nursing staff
completed a 10-hour nursing approved continuing education workshop on implementing a paced
feeding protocol with specific instructions for pacing bottle feedings for infants with respiratory
illnesses.37 The next 18 infants in the trial were delivered paced feedings. Although all feeders were
trained to use the same pacing techniques, specific techniques were not described. Infants
demonstrating one or more episodes of a transitional sucking burst and bradycardia during the first 2
minutes of feeding were paced every three sucks; whereas infants demonstrating transitional sucking
bursts without bradycardia, were paced every three to five sucks. The paced infants demonstrated a
significantly greater decrease in bradycardic incidences during feeding and more efficient sucking
patterns at discharge than infants fed by traditional methods. However, discharge date and average
weekly weight gain did not differ between the two groups. 37 The authors cautioned that feeder
training is essential for this pacing intervention. Premji and colleagues19 discussed external pacing as an
intervention to improve the coordination of suck, swallow, and breathing. They suggested that high flow
of milk may promote apnea or bradycardia episodes or otherwise compromise preterm infants. They
recommended using a firmer nipple as it permits a more controlled and manageable flow rate for the
infant and providing external pacing by tipping and positioning the infant and bottle forward to empty
the nipple, or removing the infant from the breast. The infant and bottle were tipped back or the infant
was placed back on the breast once a breath was taken. This intervention allowed the infant to swallow
without expressing milk into the mouth and to reorganize breathing and swallowing. Once the infant
had established a rhythm, the intervention of external pacing could be discontinued. The clinical
concern in using pacing is that frequently stopping and starting the nipple feeding may interfere with
the infant’s organization of sucking. Each time an interruption occurs the infant must reorganize the
pattern. These interruptions may also result in early satiety.

FEEDING SCHEDULES

The primary options for feeding schedules are ad libitum (ad lib) feeding, demand feeding, semi-demand
feeding, and scheduled interval feeding.39 The ad lib feeding starts in response to the infant’s hunger
cues and ends when the infant demonstrates satiation. Therefore, the infant determines the duration
and volume of intake.40 The demand feeding starts in response to the infant’s hunger cues, but ends
when a prescribed volume of intake is reached. This strategy is more suited to supplemental tube
feeding or bottle-feeding, than to breastfeeding as volume of intake cannot be regulated for
breastfeeding.40 For semi-demand feeding, the infant’s hunger cues are assessed at scheduled intervals
and the infant is offered a prescribed volume feeding when hunger cues are noted. Allowing preterm
infants to dictate the timing and duration of oral feeding may result in longer rest periods between
some feedings and promote infant-determined sleep and wake patterns, which reduce unnecessary
energy expenditure, increase the total nutrient intake, and increase growth rates.41 Tosh and
McGuire40 reviewed the research of the effects of ad lib or demand and semi-demand feeding versus
feeding prescribed volumes at scheduled intervals on growth rates and the time to hospital discharge
for preterm infants. They concluded there was insufficient data at present to guide clinical practice.
McCain and colleagues42 tested the hypothesis that healthy preterm infants randomly assigned to a
semi-demand feeding protocol would require fewer days to attain total oral feeding and have a
satisfactory weight gain compared with control infants receiving standard care. The control group
followed the standard practice of gradually increasing the number or frequency of scheduled oral
feedings. The experimental group was fed on a semi-demand feeding schedule contingent on infant
behavior. Infants were randomly assigned to the control or experimental group. Results indicated that
the semi-demand schedule shortened the time for infants to achieve oral feeding by an average of 5
days. Both groups had satisfactory weight gain.42 Pridham and colleagues43 compared the caloric
intake and weight outcomes of an ad lib feeding regimen for preterm infants in two different hospital
nurseries. Caloric intake for infants fed ad lib increased significantly over 5 days in both nurseries despite
differences in infant characteristics and protocol implementation between the tow settings. The ad lib
regimen did not, however, affect weight gain. Overall, it appears that a large randomized controlled trial
is needed to determine if ad lib or demand and semi-demand feeding of preterm infants affects clinically
important outcomes.

SUMMARY

Infants in the NICU who have difficulty initiating oral feeding often require evaluation and intervention
by SLPs and other health team members to facilitate the transition from tube to oral feeding and to
advance sucking and swallowing skills. There is increasing evidence that demonstrates the relevance and
effectiveness of this clinical practice for improving feeding and swallowing and related outcomes.
Systematic formats have been developed for performing clinical evaluation and observing breast- and
bottle-feeding during daily oral feedings. VFSS and FEES may be indicated when infants exhibit signs of
dysphagia affecting oral initiation, pharyngeal or esophageal phases of swallowing. Instrumental
examinations are important for determining contributing causes, revealing the pharyngeal physiology,
determining the safety of swallowing, and evaluating effectiveness of trial interventions on initiation of
swallowing and airway protection. Research has addressed the effectiveness of prefeeding exercise
strategies including oral stimulation and NNS, feeding strategies including nipple selection, cheek and
chin support, external pacing, and feeding schedules. There is a conspicuous lack of evidence regarding
positioning during feeding despite considerable expert attention to this aspect of management. Further
investigations are needed for determining the validity and reliability of assessment and intervention
strategies, the effectiveness of interventions for different infant populations, and the specific benefits
that may accrue from the use of these strategies