Preventing and Overcoming Feeding Resistance

Feeding disorders can be categorised into three areas

1. Slow to establish feeds
2. Disorganised feeding
3. Dysfunctional feeding. 

Contributing factors to disorganised/dysfunctional feeding patterns and feeding resistance:

• Delayed introduction of oral feeds.
• Prematurity.
• Birth Asphyxia.
• Neurological problems.
• Prolonged respiratory distress.
• Cardiac anomalies.
• Averse oral stimulation.
• Multiple caregivers.

Demonstrated by:

• Retching when fluid enters the mouth or pharynx.
• Desaturation, cyanosis, tachypnoea, tachycardia, periodic respirations.
• Turning head away, tuning out.
• Arching, squirming, fussing, gagging.
• Tongue thrusting when teat or nipple in mouth.
• Falling asleep when feeding attempted.
• Irritability – panic.
• Unable or refusal to suck.

Follow the steps below to encourage normal feeding patterns.

1. Encourage non–nutritive sucking especially during nasogastric feeding or prolonged episodes of NBM. Be gentle - do not forced. Consider NNS on mothers pre-expressed breast. See Newborn Service RBP: Non-nutritive Sucking :Developmental Supportive Care.
2. Promote developmental supportive care See Newborn Services RBP: Developmentally Supportive Care.
3. Commence oral feeding as soon as infant has cardio-respiratory stability. For unstable, extubated infants the decision to commence feeding should be a multi-disciplinary one.
4. Promote hand to mouth activity.
5. Minimise invasive procedures of and around the mouth.
   • Nasally intubated babies should have size 6 feeding tube down free nostril.
   • Non ventilated babies, pass size 6 feeding tube nasally unless respiratory condition does not allow.
   • Hudson CPAP babies require oral size 6 feeding tube.
   • Rationalise oral suction - only suction PRN. Insert suction catheter gently the required distance.
6. Optimise the association of oral stimulation with social activity.
7. Some infants will require respiratory support. Oxygen and oxygen saturation levels will be maintained as charted. Oxygen is a drug and any pre-planned increases during feeding must be charted by Doctor/NS-ANP.
8. Observe for feeding cues and act on them. Do not force feed.
9. Encourage gentle oral stimulation to elicit sucking action as per following instructions.

Enhancing Feeding Response

Follow the steps below to ensure feeding enhancement (improve response).

1. Conducive environment is maintained, i.e., low visual stimuli and noise levels.
2. Assess state of the baby, i.e., drowsy, active and alert. Gently rouse baby if appropriate. See Newborn Service RBP: The Sleepy Infant.
3. It may be necessary to restrict length of feeding. Rest periods may be needed to be included in this time frame. Usually 30-40 minutes depending on the infant’s ability to recover.
4. Ensure baby is swaddled gently and loosely (a muslin cloth is best for this). 
5. Ensure baby is correctly positioned, upright, slight flexion of neck. Flexed posture and arms midline. 
6. Ensure correct type of teat is used as documented in care plan by LC or SLT.
7. Consistency is maintained with continuity of care and adhering to individualised care plans. Do not change teats or feeding plan without consultation SLT, LC, FLN or CCN and mother.
8. Provide oral stimulation as per feeding plan. Mother should be taught and encouraged to do this. Refer to Newborn Services RBP: Pre-feed oral stimulation.

Cleft Lip or Palate

Refer to NWH feeding policy.

Pre-feed Oral Stimulation

Follow the steps below to provide pre-feed oral stimulation and elicit sucking action.

Note: is a very gentle procedure. Do not use undue force. If infant shows signs of distress then oral stimulation exercises should stop.

1. Ensure hands are washed. Health professionals will wear gloves however, family members do not need to.
2. Elicit a rooting reflex by stroking both checks. Start at the earlobe, moving towards corners of the mouth.
3. Stroke around the mouth 10 times or until baby begins some lip smacking activity.
4. Stroke the back of the index finger gently up across the baby’s lips to encourage a gaping response. 
5. Introduce your little finger into baby’s open mouth with the soft pad up to the roof of the mouth (fingernail down), and stroke 3 times. Watch for a response. Repeat at least 5 times.
6. Turn your finger over and stroke the tongue 3 times and wait for a response. Repeat at least 5 times.
7. Document the procedure and response from the baby.

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