NICU oral feeding portfolio
Goals of an oral feeding development portfolio for the NICU
- Attain an early transition from tube feeding to oral feeds and breastfeeding
- Utilize a combination of products, tailored according to each infant’s feeding development
- Offer a positive oral feeding experience for the NICU infant, parents and professionals
- Allow infants to apply their natural feeding behaviour
- Maintain the infant’s breastfeeding ability when the breast is not available
- Promote and support breastfeeding
Early oral exposure to human milk
As early as possible after birth, the infant should be exposed to the unique components of human milk, especially their mother’s own colostrum. For a healthy term-born infant, the first breastfeed should occur in the first hour of life; however, for a prematurely born or otherwise hospitalised infant this generally occurs later. During parenteral and enteral feeding, nourishment bypasses the oral cavity. Very early on in the development of the infant, the practice of swabbing the oropharyngeal regions can be an option to facilitate exposure to mother’s milk, even before the infant is capable of sucking.
As the infant begins to mouth and suck, other feeding options can be utilised to help the infant’s oral feeding skills develop.
Encouraging at-breast feeding
As soon as the opportunity to breastfeed arises, it should be encouraged as often as possible. This can occur in parallel to enteral feeding and oral feeding. An at-breast feed should not be considered only for the benefit of transferring milk, but also for:
- providing the benefits of skin-to-skin contact
- empowering and involving the parents
- training the infant to become more effective at breastfeeding
- stimulating the mother’s milk production
To support the NICU infant in feeding at the breast, nipple shields are commonly used in the hospital. Medela’s feeding solution portfolio includes a range of sizes of silicone Contact Nipple Shields designed to promote the latch of the infant to the breast and support the transfer of milk.
First self-controlled oral feeds
Considering the risks and constraints posed by oro- and nasogastric enteral feeding, the infant should be fed orally as early as is considered safe. Once the infant can receive sufficient nutrient volumes orally, the enteral tubes can be removed and the infant will be one step closer to leaving the hospital. In the NICU, alternative methods of providing nutrition are commonly used in parallel and as a complement to the development of breastfeeding.
Conventional bottle feeding has been questioned in terms of the extent to which it supports breastfeeding. The mechanics of feeding with a conventional bottle and teat are quite dissimilar to those required at the breast. A conventional teat allows the constant release of milk through the hole at its tip, without the requirement of a vacuum. This can challenge the infant’s ability to coordinate sucking, swallowing, pausing and breathing, resulting in oxygen desaturation and stress.
Medela has developed the research-based, innovative hospital feeding solution Calmita, which has been shown to increase breastfeeding in the hospital. It incorporates a vacuum-controlled valve that prevents milk from flowing unless the infant applies a vacuum. Calmita was designed to incrementally train infants to breastfeed by allowing them to use a vacuum and similar oral-facial muscles and positioning as they would at the breast.
The Calmita Starter has a low vacuum threshold, allowing infants who can only apply a minimum vacuum to actively remove milk. As infant feeding development progresses, Calmita Advanced can be offered, where the vacuum-controlled valve requires the infant to suck a little harder for milk to flow.
Throughout feeding development, there may be occasions where breastfeeding can be supported by offering supplemental nutrition while the infant feeds at the breast. This may be helpful for a mother with a low milk supply, or when supplements are required in addition to the transfer of milk at the breast. The Medela Supplemental Nursing System works by filling a reservoir with the supplemental nutrition. It can be placed on the mother’s chest or a pole and is connected to very thin, flexible tubes that can be fixed alongside the mother’s nipples.
Finally: full breastfeeding and returning home
As the time approaches for the infant to be discharged from the hospital, the ideal scenario would be:
- The mother has successfully initiated and established her milk supply
- The infant has developed the skills to safely and effectively receive sufficient nutrition from full breastfeeding
Reaching full oral feeds is often a prerequisite for discharge and should be an event that parents feel extremely proud of achieving. But, depending on the reason for hospitalisation, the transition from hospital to home can still have its difficulties. The provision of a discharge plan, with continual support and management of expectations, is crucial for ensuring the continuation of breastfeeding for as long as possible.
For mothers at home managing their return to work and other activities, Medela has developed Calma. This novel feeding solution helps to maintain the natural sucking behaviours that the infant has developed.
For special feeding circumstances
Medela also provides solutions for those infants who need a little extra support when it comes to feeding. The central premise of the products in the Medela portfolio is to help the infant develop the ability to create a vacuum, which is key to removing milk during breastfeeding. There are, however, special circumstances that hinder or preclude the infant from creating a vacuum.
An infant born with cleft lip and palate may be anatomically unable to create an airtight seal during feeding and therefore cannot generate a vacuum. Infants with certain syndromes and neurological disorders may also have issues appropriately generating a vacuum due to hypotonia and coordination difficulties. The SpecialNeeds Feeder is designed to allow the infant to use compression to extract milk. For smaller infants, there is a Mini SpecialNeeds Feeder available to cater for various oral anatomies.
Medeiros, A.M.C. et al. Characterization of the transition technique from enteral tube feeding to breastfeeding in preterm newborns. J Soc Bras Fonoaudiol 23, 57–65 (2011).
Siddell, E.P. & Froman, R.D. A national survey of neonatal intensive-care units: Criteria used to determine readiness for oral feedings. J Obstet Gynecol Neonatal Nurs 23, 783–789 (1994).
Geddes, D.T. et al. Tongue movement and intra-oral vacuum of term infants during breastfeeding and feeding from an experimental teat that released milk under vacuum only. Early Hum Dev 88, 443-449 (2012).
Fucile, S., Gisel, E., Schanler, R.J., & Lau, C. A controlled-flow vacuum-free bottle system enhances preterm infants’ nutritive sucking skills. Dysphagia 24, 145–151 (2009).
Lau, C. & Schanler, R.J. Oral feeding in premature infants: Advantage of a self-paced milk flow. Acta Paediatr 89, 453–459 (2000).
Simmer, K., Kok, C., Nancarrow, K., Hepworth, A.R., & Geddes, D.T. Novel feeding system to promote establishment of breastfeeds after preterm birth: A randomised controlled trial [poster]. 17th Annual Congress Perinatal Society of Australia and New Zealand, 14–17 April 2013, Adelaide, Australia (2013).
American Academy of Pediatrics – Committee on Fetus and Newborn. Hospital discharge of the high-risk neonate. Pediatrics 122, 1119–1126 (2008).
Sakalidis, V.S. et al. Longitudinal changes in suck-swallow-breathe, oxygen saturation, and heart rate patterns in term breastfeeding infants. J Hum Lact 29, 236–245 (2013).
Geddes, D.T., Kent, J.C., Mitoulas, L.R., & Hartmann, P.E. Tongue movement and intra-oral vacuum in breastfeeding infants. Early Hum Dev 84, 471–477 (2008).
McClellan, H.L., Sakalidis, V.S., Hepworth, A.R., Hartmann, P.E., & Geddes, D.T. Validation of nipple diameter and tongue movement measurements with B-mode ultrasound during breastfeeding. Ultrasound Med Biol 36, 1797–1807 (2010).
Sakalidis, V.S. et al. Ultrasound imaging of infant sucking dynamics during the establishment of lactation. J Hum Lact 29, 205–213 (2013).
Mizuno, K., Ueda, A., Kani, K., & Kawamura, H. Feeding behaviour of infants with cleft lip and palate. Acta Paediatr 91, 1227–1232 (2002).
Reid, J., Reilly, S., & Kilpatrick, N. Sucking performance of babies with cleft conditions. Cleft Palate Craniofac J 44, 312–320 (2007).
Lau, C., Sheena, H.R., Shulman, R.J., & Schanler, R.J. Oral feeding in low birth weight infants. J Pediatr 130, 561–569 (1997).