Typical Feeding Issues in the NICU
Breast-Feeding
Breast feeding may not be recommended for infants weighing less than 1,250g, due to special dietary needs. (Arvedson, Brodsky, 2002) Very small infants need higher amounts of protein and calcium than usually found in breast milk. It is recommended that the mother continues to pump her milk because of the immunological and allergy benefits. The pumped breast milk can be stored until the infant has matured enough to benefit from the breast mild or a calcium and phosphorus supplement may be added.
Formula Feeding
The formulas for premature infants specially formulated to provide 24 calories per ounce, compared with the 20 calories per ounce in standard formulas and human milk. By providing higher calorie content the formula allows the premature infant to receive the needed calories while ingesting less fluid ounces. The formulas designed for premature infants provide a protein mixture of 60% whey and 40% casein, this is similar to human milk. Traditional formula is 80% casein and 20% whey. (Arvedson, Brodsky, 2002) This special formula is helpful forming smaller, softer curds in the infant’s stomach making it easier to digest.
A study published in the Archives of Disease in Childhood shows that premature infants fed human milk or special designed preterm formula display superior developmental scores at 18 months of age, when compared to those who are fed regular infant formula. (Lucus, Morley, Cole, & Gore, 1994) Formulas that are specifically designed for premature infants have been proven to promote growth and bone mineralization similar to intrauterine rates. (August, 2002)
August, D., Teitelbaum, D., Albina, J., Bothe, A., Guenter, P., Heitkemper, M., Ireton-Jones, C., Mirtallo, J.M., Seidner, D., & Winkler, M. (2002). Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. Journal of Parenteral and Enteral Nutrition, 26(1), 97SA-109SA.
Breast feeding transition
Non-nutritive Suck
At first the infant is fed their mothers pumped milk by a feeding tube. By using non-nutritive oral-motor stimulation (NNS) the infant can practice the skills they will need for future oral feedings. It can help the infant strengthen their oral muscles therby providing a better lip seal when they are ready to nipple feed. The NNS can be done by having the child such on a pacifier, finger, or the mother’s empty breast after she has pumped her milk. This method does not necessarily trigger a swallowing response, so it should not be the only factor used in determining an infant’s readiness for oral feedings. A study by Pinelli and Symington showed that non-nutritive sucking reduced the length of a preterm infants hospital stay without posing any adverse affects if used correctly. (1998)
Stimulating Infant Sucking
Around 32 weeks gestation infants with stable respiration can tolerate brief period of stroking to help stimulate a sucking reflex. First the child is stroked on the cheeks and chin, gradually moving closer to the lips and mouth. Finally the caregiver strokes the tongue in a forward motion. The tongue is stoked at a rate of 1 stroke per second for 6-8 times. The finger is then left in the mouth to see if the child starts to suck. If not then the pattern is repeated for 5-10 minutes, unless the child shows signs of stress or fatigue, and the session is immediately stopped.
Breast feeding
An infant is ready to transition to breast feeding when they show signs of oral feeding readiness. During the feeding the infant needs to be placed in a flexed position and have jaw and cheek stability maintained. For infants that are ready for oral feedings, but need additional nourishment a supplemental nursing system can be used. A supplemental nursing system provides a regulated amount of additional breast milk or formula to the infant through a tube placed next to the nipple. The system can be phased out as the infant is able to receive more milk from the breast.
Arvedson, J.C. & Brodsky, L. (2002). Pediatric swallowing and feeding (2nd ed.). Canada: Thomas Delmar Learning.
Pinelli, J. & Symington, A. (1998). Non-nutrive sucking in premature infants. Cochrane Review.
Oral Feeding Readiness
• Position/posture- flexor
• Neck, trunk & shoulder stability
• Anatomically set for sucking
• Strong suck strength
• Can maintain lip seal
• Cheek stability
• Jaw stability for repetitive suck
• Hunger and thirst signals
• Neurologic status- organized
• Rythmic suck/swallow/breathe pattern
• Oral-motor reflexes
Arvedson, J.C. & Brodsky, L. (2002). Pediatric swallowing and feeding (2nd ed.). Canada: Thomas Delmar Learning. 305.
Bedside assessment conducted at rest
• State, posture, and position
• Sensitivity to stimuli
• Respiratory status
• Heart rate
• Oral-peripheral mechanism
Infants should be able to receive an appropriate amount of milk within 30 minutes, so that they do not expend more calories than they are taking in. In addition they should be able to take in enough calories to keep them content for a 3-5 hour periods and show adequate growth and development.
Infants usually need to be off ventilator support before oral feeding can begin. To begin oral feedings it is recommended that the infant have a resting respiratory rate less than 70 breaths per minute. Once oral feeding has commenced the infant’s respiratory rate should not exceed 80-85 breaths per minute or oral feeding should be stopped. (Arvedson, Brodsky, 2002)
A premature infant may be ready for oral feedings as early as 32 weeks, depending upon the infant’s development and other complications they may have. Most premature infants are able to be completely feed orally by 37 weeks gestation.
NG OG tube feedings
Enteral feedings may begin once an infant’s digestive system is able to tolerate human milk or formula. These feeding may be provided through orogastric OG or nasogastric NG tubes until the infants is able to demonstrate their ability to receive nutrition orally. Small infants are primarily nose breathers, therefore OG tubes are preferred by many NICU professionals.
Parenteral Nutrition
Parenteral nutrition (PN) is nutrition that is provided intravenously for infants that do not have a digestive system that is able to process nutrition. PN may be provided in the following ways:
• Peripheral vein access
• Central venous catheter (Broviac / Hickman catheter)
• Central percutaneous intravascular catheter (PIC line)
Future / New Research
Bottle Feeding Protocol
A study conducted at the Children’s hospital of Illinois compared the traditional feeding protocols for introducing bottle feedings to premature infants and a new more regulated method. The new feeding method requires that the infant successfully feed for 48 hours before the introduction of more bottle feedings, while the traditional method only required successful feeding for 24 hours. The study also showed that infants using this method could bottle feed at about 31 weeks gestational, without adverse side affects. This is an earlier age than previously thought possible.
