Monday, December 03, 2007

Suck, Swallow, Breathe

I spend a lot of time feeding preemies -- and teaching their parents to feed them. Often, the parents have the mistaken notion that practice makes perfect. For the adults involved, that may be true. For the babies, not so much.

There is a phenomenon among near-term preemies which demonstrates the issues pretty well for that group. The baby will poke along, choking and dribbling - sometimes failing to breathe as well. One day the baby just gets things together. It's almost magical - as if someone has flipped a switch. I've explained this to countless parents and recently a dad summed it up much better than I could. He said, "I see, it's like walking! He won't be able to do it until he can." The baby's mom was not exactly thrilled with any of us (dad, me, or baby), but she did seem to understand. Good thing. For that particular baby, it was weeks before he managed to pull his act together and nipple all his feedings.

Feeding preemies is much more complicated than feeding healthy term kids. With a term baby, you may have to help them figure out how to latch at the breast (or more rarely on an artificial nipple). Beyond that, the whole thing is pretty much reflex. Preemies have a pretty good suck reflex by 34-35 weeks gestation, but many don't get that swallow part. If they get the suck-swallow, they may not manage to coordinate breathing along with it. Eventually most of them will be able to manage, but it can be very frustrating for the parents while they're reaching that point.

Several things can help. First, don't cold stress the baby. They need to be warm - this often means spending time in an incubator, or at the least being dressed warmly and double-wrapped. Sometimes parents need a lot of education to understand that their preemie simply won't tolerate being unwrapped and passed around the group, especially prior to feedings. If the baby is using excess calories to keep warm, he won't have the energy to nipple or breast feed.

Preemies may not feed well if they are handled a lot or bathed just prior to a feeding. Again, they only have so much energy and need to conserve.

Positioning is important. The impulse is to snuggle the baby in the crook of your arm to feed him. This is a bad idea with preemies for 2 reasons - the baby will probably sleep if you snuggle him, and if he chokes, it will take longer to reposition him to clear his airway.

Choice of nipple can be very important. We have 4 different types of conventional nipples ( and a couple of others for babies with clefts). First is the standard nipple used for healthy term babies. I use that for most preemies as well. Then there is the "orthodontic" nipple which allegedly is more like feeding at the breast. I've never been convinced, but the nipple is quite useful for a subset of babies who choke or dribble, since it places the breast milk or formula in a different spot in the mouth. Another is softer than the others and has a larger hole. It is useful for feeding babies who have the swallow and breathe portions down, but who have a weak suck. Sometimes I use this one to finish a feeding if the baby starts to tire. The last nipple is a "slow-flow" nipple. That one is useful for the babies who have a really strong suck, but are inexperienced with the swallow-breathe portion of feeding.

Breastfeeding has a separate set of challenges in near-term preemies. Most babies take some time to develop an effective latch and suck due to a disparity between baby's mouth size and mom's nipple characteristics. It's hard for the baby to get enough of the areola into the mouth. There are ways to deal with this if the disparity isn't too great.

Mom may need a second set of hands to get the baby positioned and the mouth opened wide enough in some cases. Once the baby latches, mom needs to pull the baby in closer while she (or someone else) presses down gently on the chin to get the mouth open wider. As with term babies, it is important to make sure the lips are turned out, not in. In extreme cases, it may be necessary to use a nipple shield (silicone is best according to our lactation consultants) until the baby grows a little. I encourage the mom to try without the nipple shield first - only for a few minutes if it isn't working.

Dribbling and choking aren't a problem for breastfeeding babies unless the mom has an especially vigorous let-down. That can be managed too. We sometimes have the mother pump her breasts for a few minutes before letting the baby nurse. Estimating intake can be an issue. In most cases, we just weigh the baby's diapers to make sure he isn't getting dehydrated. In special circumstances, the baby is weighed before and after feedings (dressed and diapered). That allows an estimate of intake if that is necessary.


Mrs. Dingle said...

Great post! My son was born at 28 weeks. He was a champ at learning to nipple feed. We had a great nurse who let me breastfeed for one feeding for a full week before she introduced the bottle. I can't remember how old he was when he first started to nipple feed - but he came home when he was 34.5 weeks. We were successful at breastfeeding. We had to use a nipple shield for quite a while, and we did both bottle and breastfed until he reached his due date.
I do feel lucky that my preemie was my second child, so I had already successfully breastfed. The hospital was so supportive in breastfeeding/pumping preemies. We had a very good experience with learning how to feed our preemie.

The MSILF said...

Wow, I learned a lot from this post. I had no idea there was a cleft palate nipple, or even much of the stuff of pre-34-35 week preemies. Great!

Wabi said...

Great post! Your description of the baby forgetting to swallow brought back memories! I had my daughter at 35 weeks and that's exactly how it was with her for three or four weeks. I was very lucky to have had a term infant previously that breastfed fine, because that left me confident we could eventually get off the pump and finger feedings. And in fact, right around her original due date, we did.

NICU101 said...

Good post. Getting to the point of nippling full feeds can be so frustrating. I wish I would have read this years ago. #2 had a horrible time with milk running back out of her mouth, and they never even tried a different nipple. They also never let me breastfeed her in the unit, but that's another story!

HAINAngel2000 said...

I was a mom of 2 different preemie's. One was born at 32 weeks gestation and my other son was born 26 weeks gestation. You are right with the nursing. When my 26 weeker got around 33 weeks gestation (if he were in womb) he just latched on and never had a problem figuring it out lol. But before hand he just wasn't ready. When they are ready they are ready. Not before. What a great post!
Hey does your NICU need little hats, booties or bereavement items? Visit us I founded this Organization because of my boys and my daughter Mariah.

Beverly said...

I am so glad I found your blog. I am interested in reading about other nurses who work in the NICU.
I wish I had a nickel for every time I try to teach parents about the feeding issues. They (as your mom in this post) do not want to hear the facts, in fact, I can see the frustration in their eyes. It is so hard for them.
I will definitely visit again.

Kim said...

I just wanted to let you know how much I appreciate this post. I found it while googling desperately.. as I'm sure most moms have. I'm currently really struggling with feeding my newborn. While she was born at 37 weeks, she has major feeding issues (among other issues) and things just seem to be getting worse since getting home from the NICU. It's really wearing me out emotionally. She does pretty well for the first 1/2 ounce or so, and then completely forgets what she's doing and chokes, gags, coughs, grunts, spits it right back out.. and then cries because she is hungry and wants it so badly. It really just breaks my heart and I'm at a loss for what to do. Needless to say, I'm really glad that I came across your post.

Judy said...

Thanks for your comments! I left a reply on your blog. I hope you have someone who can help you out so you can get caught up on sleep.

Anne said...

Hi Judy,
Thank you for posting this. I am wondering when it can be expected for a premature baby to master the, "suck, swallow, breathe" cycle. Thank you.

Judy said...

They're all individuals, so it does vary. An otherwise healthy preemie with no significant respiratory disease may be able to master this by 34-36 weeks. Babies who still have breathing issues will take longer as will babies who have had bleeds into their brains.

Gina said...

I'm another desperate googler :) My baby was born at 33.5 weeks and in the NICU until 36.5 weeks. He has been home one week and it has been a roller coaster of emotions. Sometimes he latches ok, sometimes he throws fits, sometimes he nurses well (but never enough), sometimes he refuses altogether. No matter what we supplement after each feeding. First bottle, then I feared his increased rejections meant he preferred the easiness of the bottle so we finger fed, but he's refusal to nurse remained so I bought the Medela Calma bottle and we use that. Sometimes after nursing he's too tired to use that bottle though, so I've gone back to a regular slow flow Medela wide base nipple as a last resort (1-2 times per day) which he will drink from every time. I'm so drained and exhausted from trying to figure him out, we have no family near, and my husband has barely been to work for the past month and has to go back. The lactation consultants offer lots of suggestions, but honestly haven't been super helpful at pinpointing what's going on here. His due date is April 23. Things will be better by then, right? (btw, I exclusively breastfed two other (full term) children, so this is extra hard for me)

Judy said...

I'd love to promise that everything will be fine by your baby's due date. The truth is, I can't promise that because I don't know exactly what the issue is. If it's simply that he's still in premie mode, then it should get better as he grows bigger and stronger.

One thing I'd suggest, if you haven't tried this already, is to stop the bottles altogether and feed him with a medicine spoon or cup feed him. Let your breast be the only place he suckles at all. Cup and spoon feeding don't require much effort from the baby, so it won't tire him too much. It's a little messy, but gets enough supplement into the baby.

Another thought is to borrow or rent a scale and weigh before and after some feedings. Make sure he's wearing exactly the same thing (including the same diaper) for both weights. He may be getting more than you think. I don't know how often you are nursing him, but smaller, more frequent feedings -- only at the breast -- may fix this. You may end up nursing him every 1.5-2 hours, but without the additional pumping, bottle feeding, and cleanup, you might still get more rest.

It's possible that he's not too tired, but too full to take a bottle after nursing. If you don't want to risk eliminating all supplements, cut out the supplement after any feeding when he seems too tired for a bottle.

One more thing, I've found that when a baby is too hungry, it may be difficult to get him to latch. In that case, a teaspoon or so of expressed milk can take the edge off and get the baby to go to the breast.

Lavinia said...

I have an almost 38 week grandson, that was born by C-sectíon at 34 weeks. He is being fed by a feeding tube through the nose. They have tried on several occasions to get him to take a bottle, which usually ends with breathing problems. How long does it usually take to get the suck, swallow, and breath thing down. There has even been established some discussion about surgically putting a feeding tube in. I know all babies develop at different rates, but is there a time frame on when he should be feeding from a bottle, before surgically putting a feeding tube in. He has had all kinds of testing and an MRI and everything has come back normal. HELP!


Judy said...

Your grandson clearly has some complex breathing issues if he has breathing problems when offered a bottle at 38 weeks. If they are discussing a surgically implanted feeding tube, the docs must not think this is something that will be outgrown quickly. We very seldom use surgically implanted feeding tubes in my NICU, but when we do, it's to get the baby home sooner than might otherwise happen. A surgically implanted feeding tube has far less risk of aspiration than one that is put down the nose or mouth and interferes less with learning to suck. Since I don't know your grandson's history, I can't really be much help except to say that if he does need that implanted feeding tube, it will probably be temporary - but long term (as in months). One baby we sent home with an implanted feeding tube was able to do without it after about a year. I know that's not what you wanted to hear, but it's what I can offer.

Megan Allen said...

Great info, thanks for sharing!
I am an occupational therapist working on feeding with a preemie. She seems to have the suck, swallow, breathe down (no signs of choking), but her suck is very slow/weak. We have used different bottles, and pulled a needle through the nipple to make it a little bigger, but are still looking for a better option.
What brand of nipple do you use for the "softer with a larger hole"?

Thanks so much!

Judy said...

Have you tried a side-lying position? Some babies really do much better that way. Some of our nurses position the baby on their lap facing away from them to feed side-lying. I prefer to hold the baby facing me in my arms. Babies who won't eat any other way sometimes will finish an entire feeding.

We don't use any special brand of nipple, although occasionally parents will bring in something they think might help. Depending on how close the baby is to discharge otherwise, we usually wait for time and growth to correct the issue. If this really is just a gestational age problem, that's usually all that is needed and the babies usually have temperature or apnea issues that keep them with us anyway.

If this baby was a micropreemie and had a bleed or hypoxic insult adding to the slow feeding, that's more complex.

If a baby has a cleft lip, or if they have a cardiac issue which makes them tire easily, we may cross-cut the nipple to allow easier flow. That is done by turning the nipple inside out, making a small x over the hole with very sharp scissors or a scalpel, and turning it back right side out again.