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In the NICU - Feeding

Oral feeding

Oral feeding (feeding by mouth including breast and bottle feeding) is an important skill for your baby to learn. Here we explain about oral feeding and how you can help to make it easier for your baby. Staff are available to guide you – always feel free to ask.

Timing and oral skills

Your baby must have the necessary skills before they can safely try oral feeds. These skills include being able to suck well and co-ordinate this with breathing and swallowing.

Positive oral experiences will also help your baby to build their feeding skills.

Oral feeding also requires effort for your baby, so they also need to have strength and energy for this.

The timing varies and depends on your baby’s development and how well they are, as well as their age. The more preterm, small or unwell your baby, the longer it can take longer for them to be ready.

In general, babies born preterm only become ready to start oral feeds sometime from about 32 weeks gestation/corrected age and it may be a few weeks later before they can manage ‘full oral feeds’ [LINK to ‘Full oral feeds’]. ‘Full oral feeds’ means that your baby is able to drink enough milk feeds from your breast or bottle to meet their fluid and nutritional needs safely and efficiently.

Establishing oral feeds is a process and takes time and practice. The skills needed for oral feeding will continue to improve as your baby grows and matures. Take it slowly and allow your baby the time they need.

Refer to the tips below to help your baby during this transition and as they learn to feed orally.

Transitioning from tube feeds to breastfeeding

When your baby is moving from tube feeds to breastfeeding, you are encouraged to offer your baby a breastfeed as their first oral feed.

Use the time in the neonatal unit to practice breastfeeding and become confident in knowing the signs that your baby is breastfeeding well.

Continue to express while your baby transitions to breastfeeding. This is important to maintain your milk supply for breastfeeding.

If it is not possible for you to be with you baby 24/7, bottles of expressed milk may be introduced to your baby while you are not there. The process of establishing exclusive breastfeeding can then continue at home.

It may take time to establish breastfeeding, but once you have, it requires less effort to breastfeed than to express and bottle-feed.

If you do not exclusively breastfeed, you can combine breastfeeding with bottle-feeding.

Tips to help your baby when oral feeding

  • It is best to feed your baby when they are alert, calm and appear ready to feed. To help you do this, watch and listen to what your baby communicates before and during feeds and respond appropriately. Your baby communicates by showing cues. We have outlined typical feeding cues to help guide you.
  • Try to anticipate how ready your baby is before they progress to crying. Crying is a late feeding cue, and it can be difficult for your baby to feed when they are upset.
  • Do not offer feeds if your baby shows cues that feeding is too difficult or too much for them. To do so may be unsafe; it may also be distressing and exhausting for your baby.
  • Wakes, opens eyes, is alert but calm.
  • Opens mouth, pokes out tongue.
  • Turns toward breast/feed.
  • Moves hand to mouth.
  • Sucks/chews on hand/blanket
  • Increases movement, stretches.
  • Becomes agitated, cries.

Try to feed before baby progresses to late cues – it is difficult to feed when they are agitated or crying.

  • Actively sucks on breast/teat.
  • Sucks, swallows and breathes rhythmically.
  • Maintains normal colour.
  • Sucks more lightly or stops sucking.
  • Appears relaxed and sleepy.
  • Squirms, wriggles, changes position.
  • Latches/attaches poorly at breast/teat.
  • Gulps loudly, milk spills from mouth.
  • Coughs, gags as if milk is ‘going wrong way’.
  • Eyes water.
  • Breathes rapidly, runs out of breath.
  • Colour or tone changes, e.g. becomes limp.
  • Desaturates suddenly (if on a monitor).
  • Turns from feed, fights against feed.
  • Does not suck, closes mouth, falls asleep.
  • Ensure your baby is comfortable and supported.
  • Check if your baby needs to pass air/wind.
  • Comfort your baby, e.g. cuddle, hold skin-to-skin, talk soothingly.
  • Allow you baby to rest.

*Only continue to offer a feed if your baby wants to and is able to

Further information about responsive feeding and feeding cues is available at https://www2.hse.ie/wellbeing/child-health/your-babys-mental-health/understanding-your-babys-cues.html.

  • Ensure the environment is as calm and relaxed as possible. Try to avoid bright lights, loud noises and busy settings.
  • Hold your baby in an appropriate, comfortable and supported position during feeds. Positioning is crucial, so that your baby can focus their energy on feeding rather than on moving or holding their head and body up. It also helps babies to swallow comfortably at their own pace. Ask your baby’s nurse to show you. We have also included some tips here [LINK to ‘Tips to help ensure supportive positioning for your baby’].

Remember!

Prepare for oral feeding when your baby is tube-fed [LINK to ‘Tips to help your baby when tube feeding and prepare for oral feeds’]. This includes optimising and maintaining your milk supply so that it is ready too.

Tips to help ensure supportive positioning for your baby

  • Position yourself so that you are comfortable and supported. This includes supporting your back and feet and leaning back rather than forward.
  • Hold your baby close in a gently secure position. Make sure their entire body is comfortably supported, including their head, shoulders, hips and feet; and that their back is straight.
  • Make sure your baby’s head faces forward so that they do not have to turn to feed, and that it is not tilted upwards or downwards, as it is difficult to swallow in this position.
  • Check that your baby’s shoulders are relaxed and that their arms can come together easily.
  • Sometimes wrapping your baby in a light blanket can help or they may like skin-to-skin contact/ kangaroo care during feeds.
  • Do not hold your baby by the base of their head and ensure they can move their head at all times.
  • Keep your baby slightly elevated during feeds (head higher than the bum!).
  • Avoid handling or moving your baby too much during and after feeds, and avoid pressure on their tummy, for example tight-fitting clothes or slouching in a car seat or bouncer-seat.
  • Explore how your baby likes to be held during feeds. Different holding positions can help different babies, for example a ‘cross-cradle’ or ‘football/under arm’ hold can suit some breastfeeding babies, while a ‘elevated side-lying’ position may suit if your baby is bottle fed. Ask your baby’s nurse to help work out what suits your baby best.
  • Swap the side you hold your baby at alternate feeds or halfway through feeds if they take a break. This helps their muscles to develop equally on both sides.
  • After feeding, support your baby in an upright position and allow them to pass air (wind) if present.

Align photos with the relevant text above

How to feed?

  • Allow your baby to pace the feeds. Follow your baby’s natural rhythm of sucking, swallowing and breathing. They should not gulp. Your baby may want to pause many times during a feed. This allows them to rest and recover their energy to continue feeding.
  • When your baby is transitioning from tube feeds to oral feeds, they may be only able to start with a small oral feed just once a day; but as they become stronger and their feeding skills improve, they will gradually increase the size and frequency of oral feeds.
  • If your baby gets tired during an oral feed, you can provide the remainder of the feed as a ‘top-up’ through a feeding tube. In the early days of oral feeding, you may need to offer your baby a ‘top-up’ after each oral feed or you may need to give entire feeds through the feeding tube; but over time, as your baby’s oral feeds increase, tube feeds will gradually reduce.
  • When breastfeeding, you can gauge the amount of milk your baby feeds at your breast by watching for signs that they are feeding well. There are breastfeeding assessment tools that may also be used. Ask staff to guide you.

If your baby does not feed fully at your breast, you need to express your milk to maintain your supply. This milk can be provided as a ‘top up’.

  • If bottle feeding, use a ‘paced bottle feeding’ method. This is explained here, together with other tips on bottle-feeding.
  • Try to be patient, getting oral feeding going takes time and needs to go at your baby’s pace. Follow your baby’s lead and only progress as they are able.

If your baby has difficulty feeding, they may be referred to a speech and language therapist for assessment and guidance. They may also benefit from additional supports designed specifically for them following assessment of their feeding skills.

Tips when breastfeeding to know that your baby is latched and feeding well

  • Your baby’s mouth is open wide and their cheeks appear ‘full’ and rounded.
  • Your baby’s chin is tucked closely into the breast and they can breathe easily.
  • Your baby’s sucking pattern changes to long deep sucks and swallows, with pauses in between.
  • You hear slow, deep, rhythmic, sucking and swallowing sounds; and no smacking or clicking sounds.
  • Your baby feeds calmly; they do not fuss or come on and off the breast.
  • Your baby finishes feeding and seems satisfied.
  • You do not feel pain.

From HSE resource ‘Breastfeeding and Expressing milk from your premature and sick baby’ (HSE, 2021).

“I’m amazed I am breastfeeding. I hadn’t planned to do any of this, but now that I am, I’m going to keep going as long as I can. It’s lovely.”

Quote from NMH mum in The NMH

Bottle-feeding

Bottle-feeding is not the same as breastfeeding. If your baby bottle-feeds, some additional tips are outlined here.

Tips when bottle-feeding your baby

Ensure that feeds are prepared correctly and at a suitable temperature for your baby. Also, make sure that any air bubbles that may be in the feed after preparation have disappeared (settled).

  • Offer bottle-feeds using a ‘paced bottle feeding’ method. This is important, to help your baby to control the flow rate of the feed.
  • Hold the bottle almost level (horizontal). A slight tilt is ok, just enough to ensure that the teat is filled with milk and not air. A bottle held this way will slow the flow of milk and allows your baby to control the flow.
  • Allow your baby to set the pace of the feed and to pause as often as required.
  • When your baby pauses, tip the teat up towards the roof of your baby’s mouth to stop the flow of milk.
  • When your baby starts sucking again, lower the bottle again to the horizontal position.
  • Check that the teat and flow rate suit your baby, i.e. that it is neither too fast causing them to gulp, nor too slow causing them to suck too much to get feed out. A suitable teat can help your baby to feed more effectively. There are different teats that may be used but check with staff first before making any changes.
  • During feeds, make sure that your baby maintains a good seal around the teat with their lips, that their tongue stays below the teat, and that the teat is always full of milk.

Further guidance on bottle feeding is available at www.mychild.ie https://www2.hse.ie/wellbeing/child-health/bottle-feeding/equipment-for-bottle-feeding.html]

https://www2.hse.ie/wellbeing/child-health/expressing-breast-milk/using-a-bottle-to-give-expressed-milk.html https://www2.hse.ie/wellbeing/child-health/combination-feeding-breast-milk-and-formula.html

When to move from a scheduled to a responsive feeding plan?

In the early days, if your baby is very preterm or unwell, they may need to follow a scheduled feeding plan where feeds are offered at regular intervals. As your baby grows and matures and their feeding skills improve, feeding can start to become more responsive. When your baby is mature and well enough to be able to complete all feeds orally, they can generally move from a more scheduled feeding plan to a more responsive plan. For babies born preterm, this tends to happen gradually as they mature and become stronger, but we expect most babies to be able to feed responsively as they approach term – their due date.

When your baby is feeding responsively, they will work out the amount they need to meet their needs and the feed pattern that suits them best.

Some less mature or unwell babies need extra support with feeding or may need to follow a more scheduled feeding plan for longer, for example if your baby does not show signs of hunger or tires easily.

How much and how often to feed?

The amount and frequency at which your baby feeds may vary. This is fine once your baby is well and demands enough feeds to meet their needs.

By the time your baby is going home, we expect they will be feeding regularly, at least 6–8 times daily. Some babies prefer smaller more frequent feeds, others prefer larger less frequent feeds, and others vary the size and frequency over the day and night, e.g. more frequent feeds at certain times and less frequent feeds at other times.

When your baby is small, their tummy is small too, and so they may only be able to take small feeds at a time. As a result, they need to feed more often. As your baby grows, you can expect them to increase the size of their feeds and reduce the frequency.

During growth spurts, when your baby grows a little faster, they may also look to feed more often. This extra sucking and feeding will help you to make more breast milk to meet their increased needs.

Similarly, if your baby was born preterm or is smaller than expected for their age, they may want to feed more often or take bigger feeds relative to their size compared with other babies. This is normal and just their way to ‘catch up’.

Catch up growth

Babies who are born preterm or smaller than expected tend to grow faster to ‘catch-up’ and reach the size that is more appropriate for their actual age. They do this by increasing how much they feed. The timing varies, but most babies ‘catch up’ at some stage over the first one to two years.

If your baby appears hungry and wants bigger and/or more frequent feeds, it may be that they are going through a growth spurt or trying to ‘catch up’.

How long for feeding time?

We expect your baby to take no longer than about 20-30 minutes to complete each feed. If your baby is unable to complete feeds within this time, let your baby’s nurse or doctor know.

Whatever your baby’s feed pattern, make sure they have enough time to rest between feeds. Feeds should not be so long that they interfere with your baby’s need for rest and sleep.

Remember!

Focus on the quality of feeding - not just the quantity of feed. Feeding should be pleasurable for both you and your baby.