1. Key issues in supporting transition from tube to
bottle feeding
Gillian Kennedy
Consultant Speech and Language
Therapist
NIDCAP Trainer in training
Neonatal Unit
University College London Hospital
London.
gillian.kennedy@uclh.nhs.uk

3. .......por lo tanto

4. -Baby
-Maternal
-System
(hospital /
social)

5. Key issues in supporting transition from tube to
bottle feeding

6. Early input to redress negative peri-oral stimuli
Negative
• Intubation
• Suction
• CPAP
• Feeding tubes
Positive
– Skin to skin / kangaroo –
mother care
– PositiveTouch
Bond 1997

7. Influence of tube feeding
OGT
NGT
•Rate of flow
•Contact with baby
•Position of baby

8. Strategies to promote oral feeding have included:
Early introduction of oral feeds Oral stimulation programmes
Boiron et al 2007
Fucile et al 2002
Barlow 2009
31 weeks vs. 33-34 weeks ga
Simpson et al 2002
Specific feeding techniques
e.g. cheek and jaw support
Eishema 1991

9. Quantative outcome measures related to..
• Volume
• length of feed
• Speed of transfer from
tube oral feeding
– e.g.
Entire prescribed volume
taken within 20 mins
without adverse effects......
Usually defined as apnoeic +/-
bradycardic episodes

10. Influence of individualised care
..based in NIDCAP approach Als 1982
Shift in feeding
outcome focus from..
Quantative
Qualitative

11. Als Synactive Theory of Development
• Physiological
• Motor
• State
• Attention / interaction
• Self regulatory

12. Focussing on the feeding experience for
the baby
• Baby viewed as an
active participant
• Co-regulation from the
parent / carer to:
– Facilitate and support
the baby’s own efforts
– identify and respond to
the baby’s signals of
sensitivity

13. Feeding readiness behaviours
White-Traut et al 2005
Thoyre et al 2005
• Alert – baby demonstrates the
ability to focus attention on
feeding
• Rooting
– Neurodevelopmental readiness
Shaker 1996
• Tongue organised to receive
nipple
• Body posture orientates to
midline – arms forward to
assist
• > 90 % baseline oxygen
saturation level in quiet state
and in preparation period.

20. 34-36 week infants
• Feeding issues for late
preterm infants:
Bottle and Breast fed
Dodrill et al 2005
Meier et al 2007

21. Babies with Chronic Lung Disease
• Anticipated maturational patterns of
suckle and swallow rhythms do not
occur.
• ?does the absence of stable rhythms
at 35 weeks predict subsequent
feeding and neurological problems
Gewolb et al 2001
• > incidence in gastro-intestinal issues
Jadcherla et al 2010
• > incidence of feeding difficulties
Hawdon et al 2000

22. Modifications to introduction of oral intake for
bottle fed babies weaned from long term CPAP
• EBM used for initial trial
Mizuno & Ueda 2002
• Elevated side-lying position used

23. Positioning is important because:
• Cranio-cervical posture and
pharyngeal airway stability
are interconnected
• Premature infant lacks the
éxoskeleton’ and strong
physiological flexor of the
term infant.
Bosma 1972
• Feeding success strongly
influenced by the feeders
body mechanics
Jones et al 2002

24. Positioning

31. Elevated side lying
• Conserves energy
• Affords baby more control
over feed
• Facilitates infant using
self-regulatory strategies
• Enables safer clearance of
oral residue
• Allows feeder to feel
respiration

32. Pilot study investigating the elevated side-
lying position Clark et al 2007
• Improved oxygen saturation levels
……..when infants fed in elevated side-lying versus
semi-upright
p < 0.001
Trend
• Quicker return to baseline of heart- rate
Further research presently underway