The neurologic maturation required to coordinate the complex reflexes of suck-swallow-and breathe is usually achieved around 34 weeks postmenstrual age. Infants born prematurely usually learn to achieve this skill while receiving enteral feeds by gavage. The transition from gavage feeding to po feeding is an important developmental period for premies.

Former preterm infants are at risk for neurobehavioral problems including oral aversion and feeding difficulties. Although these problems are not well understood, research suggests the following:

1. prolonged tube feedings, past the point of po feeding readiness, may increase the risk for oral aversions,
2. feeding babies po before they have sufficient neurologic coordination and behavioral control increases not only the risk of aspiration, but also of oral aversions.

Taken together these two findings suggest that the timing of initiation of po feedings should vary based on the individual infant’s developmental maturity, and that the infant should be allowed to control the pace at which his/her po feeding progresses depending on behavioral cues.

A recent "semi-demand" po feeding protocol studied and reported in the September 2001 issue of Pediatrics appears to accelerate the preterm infant’s achievement of full po feeding in a developmentally-friendly manner that may decrease later problems with oral aversion.

Currently, this protocol is being used in the VUMC nurseries for former preterm infants with minimal respiratory disease (NC O₂ < 0.1Lpm) who are tolerating full bolus OG feeds.

Infants should be assessed for signs of po feeding readiness at a post-menstrual age of 32 – 34 weeks. Signs of po feeding readiness include prolonged periods of quiet alertness, sustained sucking on a pacifier, and fighting OG tube placement.

When the infant demonstrates an interest in po feeding, an indwelling silastic NG tube should be placed, and the OG tube abandoned. The NG tube may remain in place until full po feeds are achieved.

Every 3 hours at feeding time, the nurse should assess the infant’s physiologic stability and behavior. If the infant rejects arousal and remains in light or deep sleep, the entire feeding volume should be administered by NG tube.

If the infant awakens and is drowsy, quietly alert, active, or crying, the infant should be offered a pacifier and allowed to suck for a few minutes to come to a state of feeding readiness. The infant should be encouraged to "root" for the bottle. While po feeding, pace the infant to assist in coordinating sucks and swallows. Monitor the infant’s behavior for signs of fatigue or distress.

If the infant shows signs of fatigue or distress, the po feeding session should be terminated. Stop po feeding if the infant:

1) Falls asleep

2) Will no longer suck, even after being burped

3) Exhibits signs of moderate distress including: sighing, yawning, sneezing, hiccupping, repetitively swallowing, facial grimacing, jaw trembling, squirming, straining, averting gaze or alterations in body tone

4) Exhibits signs of major distress: arching back, coughing, choking, gagging, apnea, bradycardia, or color changes.

Give the remainder of the feeding volume per NG tube.

The nurse should document feeding tolerance, and progression should be monitored and addressed daily.

Because this is a relatively new protocol to the Vanderbilt nursery, changes in our patients’ outcomes will be closely monitored to assess this feeding strategy. Until we document positive results, we hesitate to place NG tubes in infants with significant chronic lung disease and high O₂ requirements as infants are preferential, if not obligate nasal breathers. Historically, indwelling NG tubes were associated with an increased incidence of otitis media, and this diagnosis should be in the clinician’s differential if a previously well and growing premie with an NG tube begins to act ill.

Lastly, also in the interest of decreasing later symptoms of feeding aversion, the fast-flowing red nipples SHOULD NOT be used in premies learning to po feed. Although the milk volume may disappear into the infant quicker, this nipple does not allow the infant to control flow rate and does not encourage suck-swallow-breathe coordination and feeding competency.

References:

McCain GC, et al. A feeding protocol for healthy preterm infants that shortens time to oral feeding. J Pediatr 2001; 139: 374-9.

Gill NE, et al. Effect of nonnutritive sucking on behavioral state in preterm infants before feeding. Nursing Research 1988; 37: 347-50.

Mathew OP. Breathing patterns of preterm infants during bottle feeding: role of milk flow. J Pediatr 1991; 119: 960-5.

Resolved at the Collaborative Pathways meeting 11/14/01.