While there are many criteria for discharge from the neonatal intensive care unit (NICU), eating well enough to gain weight and do so without significant physical distress are two commonly used criteria to determine readiness to discharge home. However, infant competency with the task of eating is variable and feeding continues to be a source of concern after discharge for many families. Infants may be discharged with supplemental tube feedings prior to achieving full oral feeding, or eating with poor coordination. The assumption is often that feedings will improve naturally after discharge.
Earlier born preterm infants are later at achieving full oral feedings while in the NICU, and demonstrate increased difficulty with eating compared to more mature, preterm infants. However, studies indicate feeding problems in the first years of life are more common for all infants born preterm compared to full-term counterparts. After discharge, preterm infants are slower to develop eating skills required to transition to a wide variety of age-appropriate foods. Additionally, parental reports of feeding problems are prevalent, and parents frequently introduce solids to their infants earlier than recommended in an attempt to improve weight gain.
Eating
Refers to the abilities of the child.
Considered a neurodevelopmental process that follows a predictable sequence of acquisition of skills. However, the timing of acquisition is variable in much the same way as in other areas of development.
Requires the infant to organize
Autonomic function
Oral-motor skills
Muscle tone and movement patterns
Behavioral state
And, have the ability to regulate all of these processes simultaneously.
This task becomes increasingly challenging as the demands increase with the introduction of solid foods.
Infants with greater severity of illness or number of medical interventions are at greater risk of feeding problems and demonstrate greater delay in acquisition of eating skills.
While the infant establishes a rudimentary foundation for eating within the NICU setting, eating skills continue to develop and new skills must be acquired by the infant in order to transition to a wide variety of age-appropriate foods by age 3.
Oral-motor anatomy and skills undergo multiple transitions across the first 3 years of life.
Gross motor and fine motor skills are increasingly necessary to transition to self-feeding.
As the infant matures and becomes more aware of themselves as an individual, food preferences begin to develop.
At each of the major transition points infants may struggle to consolidate the new skills required.
Providers often believe that the infant is not at further risk of feeding problems when the infant is discharged from NICU to home if they leave without the need for supplemental feedings via a nasal-gastric or gastrostomy tube. However, given the neurodevelopmental nature of eating, it is evident that eating a prescribed volume while in the NICU is not a predictor of successful eating after discharge.
Extremely premature infants are 3.6 times more likely than term infants to have an eating problem when evaluated at 6 years of age.
The preterm infant’s eating and growth need to be closely monitored, so that emerging areas of concern are quickly identified. The earlier the concern is addressed, the less likely the observable mealtime behaviors are to solidify into problematic behaviors that persist into later childhood.
Feeding
Refers to the abilities of the caregiver and the entire experience of the meal.
This chapter enhances professionals’ understanding of feeding development and the difficulties faced by parents when feeding preterm and high-risk infants.
Normal development of eating skills
Sucking comprises two components.
Positive pressure (compression) that pushes fluid out of the breast or bottle.
Negative pressure (suction) that pulls fluid out of the breast or bottle.
Normal, term infants begin life with compression-only sucking (eg, mouthing), and integrate suction over a period of a few weeks, resulting in a rapid improvement in feeding efficiency and volume.
A central pattern generator (CPG) provides the rhythmical pattern for sucking/swallowing and breathing bursts through networks with musculoskeletal effectors.
Typical mealtime duration is 10 to 20 minutes, or approximately 10 mL every minute, once the normal, term infant has fully integrated suction.
From a sensory development standpoint, taste buds develop very early in gestation.
The majority of taste buds are on the dorsal surface of the tongue, palatoglossal arches, palate, posterior surface of the epiglottis, and posterior wall of the oropharynx.
The majority of taste is presented to the back of the infant’s mouth during breast- or bottle-feeding.
Infants develop preferences for odors that are presented in the first 1 to 2 days of life, with the majority of smells provided during breast-feeding or formula feeding.
Gross and fine motor skills minimally influence infant feeding in the healthy, term infant.
Birth to 3 months
Infant oral-motor skills differ significantly from later stages, as these skills are driven primarily by primitive reflexes, including
Rooting (head turning toward a stimulation to the cheek or lips)
Extrusion (tongue protrusion and movement for latching on to breast or bottle)
Sucking (rhythmical movements of the tongue and jaw)
Prior to the introduction of solids, these primitive reflexes must be integrated to allow for more sophisticated movements necessary for eating solid foods. After approximately 4 months of age feeding is voluntary and the infant must know how to eat without the use of these reflexes.
There are also protective reflexes that remain in place to protect against choking and/or aspiration, including
Gagging (rhythmic movement of the tongue and pharynx in an attempt to expel food or liquid from the posterior surface of the tongue and/or pharynx and protect the airway)
Coughing (sharp expulsion of air in an attempt to clear the airway)
Laryngeal chemoreflex (closing of the vocal folds in the larynx in response to the presence of acidic or organic substances reaching the laryngeal mucosa). In the preterm infant, it may result in apnea, bradycardia, and a loss of muscle tone; in the term infant, it triggers an arousal and cough.
Infant aerodigestive anatomy prior to 4 months of age differs significantly and is believed to be protective of the infant’s airway to support the transition from intrauterine to extrauterine life.
The oral space is filled completely by the tongue in the infant, and the oral structures are vertically compressed.
The tip of the epiglottis is at the cervical level C-2/C-3.
3 to 6 months
By 4 months
The infant integrates the primitive reflexes of rooting, extrusion, and sucking.
As the cortex matures, the CPG no longer provides the sucking pattern, and feeding becomes a voluntary activity.
The mandible grows downward and forward, and the larynx descends until, by approximately 5 months of age, the upper aerodigestive tract resembles that of an adult.
This shift supports the transition to baby cereal/solids. Initially, as the food is presented to the anterior oral cavity the infant struggles to actively move the food posterior, as this oral-motor pattern differs from the combination of suction and compression used to draw fluid out and into the pharynx. Infants often protrude their tongue in anticipation of the spoon when it is presented.
By 6 months of age
Most infants are offered two solid feeds per day.
Mean duration of mealtimes for infants with typical feeding skills is 20.3 minutes (range of 16 to 22.5 minutes).
In this age range, the various flavors provided by baby cereals and pureed solids stimulate the taste buds with a wider variety of tastes. The flavors are now presented at the anterior oral cavity, rather than at the posterior oral cavity as was the case with breast and bottle-feeding.
Infants are orally exploring everything in their world, including their own hands and feet, teether toys, and clothing. This oral exploration assists in desensitizing the tongue to more solid textures, in preparation for transitioning to solid foods.
Gross and fine motor skills are more involved as the infant begins to sit in a feeder chair for solid feedings and reach for the spoon.
The infant begins to visually anticipate the spoon, and to engage in the reciprocal task of feeding with their caregiver.
Spoon feeding also provides an opportunity to learn joint attention to the spoon, and turn taking, with both infant and parent positively reinforcing each other’s behaviors.
6 to 9 months
Between 6 and 8 months of age, most infants are eating thicker baby cereal/solids, and by nine months many begin eating some finger foods, characterized by a meltable texture.
The introduction of finger foods increases the sensory stimulation for the infant during mealtimes.
Finger foods have different visual, auditory, tactile, taste, and smell properties from each other.
As the infant begins to eat the finger food, they must integrate the changing properties of the food. For instance, the tactile input (feel) of a meltable cracker will change from a firm cracker to a fine mash as the infant chews on the piece.
Between 6 and 12 months of age, the average number of meals offered to a child is 11, including breast, bottle, and solid feeds.
Infants develop a “munching” chewing pattern, with a vertical movement of the mandible.
The infant learns how to hold pieces of foods placed on their gums using the side of their tongue and cheek, but lacks the ability to volitionally move pieces onto their gums with their tongue. Frequently, infants use their hands/fingers to place the foods on their gums and to move the foods around in their mouth.
Tongue protrusion develops to help clear food off of the lip, and lip closure improves with the introduction of meltable food textures requiring chewing. More food remains in the infant’s mouth as lip closure matures.
Parents begin offering soft cubes of foods and soft mashed pieces of table foods toward 9 months of age.
Mealtimes continue to last approximately 20 minutes.
Gross and fine motor skills are more challenged in this age range as well. Most infants will be seated upright for finger feeding, and, therefore, must have developed good trunk and head control. Fine motor skills are necessary for the infant to be able to reach out and pick up pieces of foods.
9 to 12 months
Between 9 and 12 months, most infants begin eating mixed textures, in addition to small, chopped pieces of table foods.
The infant perfects the ability to move pieces in their mouth using only their tongue, and as the tongue becomes more efficient the infant ceases to use their fingers for food placement/movement.
They have developed good lip closure, and move foods fully from one side of the mouth to the other, using full lateral tongue movements.
As infants increase strength and practice chewing solid foods, they develop a more mature chewing pattern, called an “emerging rotary chew.” A rotary chewing pattern involves a lateral shifting of the mandible rather than a simple vertical motion of the jaw. Lateral shifting is required to “shred/grind” more textured foods, such a fruit/vegetable skins and meats. Initially this chewing pattern will occur sporadically within a munching pattern.
Gross and fine motor requirements again increase as trunk stability must be sufficient to fully explore the tray and self-feed.
12 to 18 months
Beginning at 12 months of age, the average number of meals decreases to seven meals per day, as the toddler eliminates breast- and bottle-feedings and transitions fully to finger and table foods.
The typically developing toddler is proficient at moving foods in their mouth, and chewing meltable and softer meats/vegetables and cubed foods. They continue to work on transitioning to a rotary chewing pattern as they are offered more textured foods. Chewing skill improves and the rotary chewing pattern becomes more predominant, resulting in improved efficiency.
Around 16 to 18 months of age, most families introduce utensils to their child. Spoon and fork use will be inefficient at 18 months as the food often falls off of the utensil. Finger feeding is a more efficient way of eating for most children in this age range.
Toddlers begin to exert their independence as they undergo an emerging sense of self, and begin to reject foods that they have typically eaten, and to say “no.” Toddlers express their food preferences, and parents who are unaware of this developmental shift in cognition are often tempted to only offer foods to their child that they are sure the child will eat. Parents must learn to navigate this emergence of independence without power struggling or restricting the diet of the child. Toddlers become less picky when they are offered a variety of foods, even if they do not eat the offered foods at that time.
18 to 36 months
Skills in this age range do not typically change drastically, but the previously learned skills of biting, munching, and rotary chewing become stronger and more precise.
Utensil use is perfected, allowing the child to eat the same foods as the rest of the family and fully transition off baby foods.
The toddler and preschool-aged child is increasingly becoming self-aware and often attempt to eat the same foods day after day as a way to assert their control. The balance between offering novel foods and offering more familiar or preferred foods is difficult to achieve, but an important skill for parents of children in this age. Most of a child’s food preferences are formed between 2 and 3 years of age.
Differences in development of feeding skills in preterm infants (Figure 47-1)
Quantity versus quality (Figure 47-2)
Many preterm infants, while eating sufficient quantities to discharge home, may still be struggling to eat efficiently or in a smooth, coordinated fashion.
Infants may have problems with
Difficulty latching
Fatigue during feeding and struggle to finish the full prescribed volume
Liquid loss
Short sucking bursts
Poor organization of suction and compression components
Noisy swallows
Feeding intolerance/reflux/vomiting
Strategies to improve feeding quality include
Improve stressful environment
Control flow rate (change nipple, pacing, swaddling, jaw support, etc)
Medically manage negative feedback (CLD, GER, aspiration, etc)
Eating skills are highly correlated with overall development, especially in the first years of life.
Gross motor, fine motor, and oral-motor skills, as well as cognitive development, all support transitioning to solid foods across the first 3 years of life.
Expectations should be based on corrected age rather than chronological age of the child.
Studies of oral-motor skill development reveal preterm infants often lag behind in skill acquisition, even when corrected ages are used.
Feeding skills in preterm infants across the first year of life, correcting for prematurity.
1 Month’s corrected age
Less than half of infants mouthed or sucked on their fists.
Only half of infants demonstrated distress when the feeding was interrupted.
4 Months’ corrected age
Only one-quarter of preterm infants grasped the bottle and drew it into their mouth, brought their hand to mouth when the nipple was removed, or looked at their hands.
Only half of preterm infants reached for objects and grasped them, used both hands to grasp objects, looked at objects in their hands, flexed their body toward breast or bottles, or looked at caregivers during feedings.
For the 21 behaviors related to a feeding, 17 of the skills were observed in less than three-quarters of the infants at this age.
8 Months’ corrected age
Only about one-third of infants demonstrated a munching/smashing pattern with their tongue and jaw.
Approximately half of infants were feeding themselves crackers or larger pieces of finger foods, helping feed by grasping the oncoming spoon, or vocalizing impatience or eagerness in response to the caregiver preparing a meal.
Only half explored foods with their hands.
Fewer than three-quarters of preterm infants were performing the skills for 21 of the 31 expected skills.
12 Months’ corrected age
Fewer than one-third of preterm infants were using their tongues to lick food off of their lips or getting any food into their mouth with a spoon.
Seventeen of the 21 expected skills were evident in fewer than one-quarter of the preterm population.
Even low-risk populations of preterm infants have poorer eating skills at 4, 8, and 12 months of age (corrected) when compared to those of term infants.
Preterm infants required a greater number of feedings per day, and the mean duration of both breast/bottle-feedings and solid feedings was significantly longer.
Preterm infants took longer to transition to textured solid foods, even though they were started on pureed solids foods earlier than the term infants.
Preterm infants also took longer to transition to cup drinking and self-feeding.
Mealtime behaviors of the preterm infants were more difficult and parents reported more feeding-related stress and more concerns regarding feeding skills than those of term infants.
A large difference between parental expectations and infant skills that lag behind expectations may contribute to the mealtime struggles so commonly reported by parents of preterm infants.
10% to 15% of parents of both early preterm (<34 weeks’ gestation) and late preterm (34 to 36 weeks’ gestation) infants report ongoing concerns regarding low appetite.
2% to 4% of parents report ongoing high avoidant behaviors during feeding, and a small percent report oral-motor dysfunction across the first year of life.
“Picky eating” behaviors (eg, wanting to eat only certain types of foods on a repeated basis) are also common, as are the use of rewards such as caregiver coaxing or bribing with a preferred food.
Weight gain may become an area of concern, as the infant transitions through breast-or bottle-feeding as the primary source of nutrition and skill deficits interfere with eating sufficient quantities of solid foods for weight gain.
The duration of mealtimes may become problematic over time as well, due to disruptive mealtime behaviors. Parent reports of a mean duration of 37.5 minutes per mealtime at 24 months, in children reported to have feeding disorders at 6 and 12 months.
Many infants do not transition fully to breast-feeding after discharge from the NICU (see Chapter 12).
Feeding skills in the medically complex infant
The younger the gestational age at birth, the longer it takes to establish oral feedings.
For infants born at less than 28 weeks, the mean gestational age for attaining “maximal oral feedings” is 36.6 weeks.
50% of infants born at less than 28 weeks are discharged home primarily nipple feeding along with supplemental tube feedings. 14% required a gastrostomy tube at the time of discharge.
At 6 months’ corrected age, extremely low birthweight infants have significant ongoing feeding problems such as inconsistent oral-motor skill development, fewer self-feeding and biting skills, and fewer behaviors indicating a readiness for solids.
Comorbidities commonly interfere with the development of age-appropriate feeding skills (Table 47-1).
The most problematic comorbidities include respiratory disease, cardiac conditions, gastrointestinal disorders, congenital disorders, structural abnormalities, and neurological impairments.
For infants with medical comorbidities, a Video Fluoroscopic Swallow Study may be beneficial to verify safety with oral feedings (see below).
Most medically complex infants also benefit from therapeutic intervention by a speech and language pathologist (SLP) or an occupational therapist (OT) with specialized expertise in infant feeding. Additionally, most infants will benefit from a consultation with a registered dietitian who can help maximize caloric intake. Therapists working with registered dietitians can recommend foods that are high in nutritional value and are orally manageable for the infant.
Assessment tools
When an infant is not eating well, the first step of a formal evaluation is a medical examination to address any potential acute factors. Additionally, infants who are aspirating typically will have pulmonary changes. The second step would be to refer the infant and family to a feeding specialist—typically an SLP or OT. If the infant has medical comorbidities, a multidisciplinary team assessment is often more beneficial than an evaluation conducted only by a therapist. The therapist should collect a full history of the infant and the past feeding experiences.
Growth chart
As with other areas, growth percentiles should be plotted using corrected age, rather than chronological age, through at least age 2.
Changes in weight-for-age percentiles may provide an early indication of poor feeding skills or difficult mealtime behaviors.
While a downward shift in percentiles may not be cause for alarming the parents, it may be helpful to use this marker as a prompt to ask about mealtime duration, difficulties in feeding the child, and skill deficits. Parents often are doing extraordinary things to keep their infant growing; weight gain is not necessarily a sign that feedings are pleasant events.
Subspecialty evaluations
The majority of children seen in tertiary feeding clinics have both developmental and medical issues, with only 2.5% of children demonstrating a true “behavioral” feeding disorder with no underlying physical problem.
When a medical etiology is suspected, an appropriate referral should be made to the area of specialty (eg, gastroenterology).
Among other medical problems, just over half of the children had gastrointestinal problems, with just under one-third having either a neurological, cardiopulmonary, or food intolerance issue in conjunction with their feeding disorder. A complex medical history that includes any of these issues may lead to a learned aversion to eating, even when the initial medical concern has been resolved.
Since feeding disorders are frequently complex, many children with ongoing feeding issues often need to be evaluated by a multidisciplinary team to ensure that all of their medical needs, developmental skills, and learned avoidance behaviors are evaluated.
Behavioral pediatrics feeding assessment scale
The only mealtime behavior questionnaire, by Crist and Napier-Phillips (2001), has both normative and clinical population data.
The scale includes checklists for both child and parent behaviors, with the frequency of the behavior separating typical compared to clinical (abnormal) populations.
Instrumental evaluation of swallowing
A clinical evaluation should be conducted prior to an instrumental evaluation, as often the feeding problem is a refusal to eat, rather than a structural dysfunction. The clinical evaluation will assess the infant’s abilities and desire to eat, as well as the oral-motor and sensory components of the feeding experience. Once the infant is willing to orally take even a small amount of food, instrumental evaluations may be ordered.
Video Fluoroscopic Swallow Study (VFSS)
Most common diagnostic study of swallowing
The primary purpose is to determine the safety of the pharyngeal swallow and identify if there is aspiration during swallowing.
Benefits include the ability to visualize the oral, pharyngeal, and esophageal phases of swallowing, as well as to examine structures.
The limitation of the VFSS is that it captures only a brief window rather than an entire meal. Therefore, a negative finding does not rule out aspiration across all conditions. However, a positive finding of aspiration then should lead to therapeutic interventions to improve the safety of the swallow.
Fiberoptic endoscopic evaluation of swallowing (FEES)
The FEES allows for a flexible fiberoptic endoscopic evaluation of the nasal, pharyngeal, and laryngeal structures, as well as structures immediately prior to, and after, a swallow.
Residual fluids can also be visualized.
Benefits include readily available in most hospital settings, no radiation exposure, observation of the structures, and positioning of the infant is most flexible.
The limitation of the FEES is that the entire dynamic swallowing sequence is not observable, and aspiration may not be observable.
Common interventions for reducing aspiration in infants include
Slowing the flow rate of the fluid from the bottle.
Slow flow rate, using a slower flowing bottle, can allow the infant additional time to swallow.
Facilitates more control over the bolus size.
Fluid thickening
Also slows the flow and allows for more control over the bolus size.
Recent concerns regarding the use of thickening agents (commercial thickeners as well as rice cereal) have included the slowed transit time for digestion as well as lack of consistency across brand names to meet specific viscosity parameters. Xanthan gum-based thickeners have also been associated with an increased risk of necrotizing enterocolitis in infants, even postdischarge.
The viscosity of all thickeners changes over short time periods, which influences the effectiveness of the intervention.
Parental follow-through may also be variable with thickeners, as they may begin to decrease the viscosity of the fluid when the infant does not take sufficient volumes of the thickened fluid.
Thickened fluids are also more challenging to extract from the bottle, and must be given via a bottle, eliminating the possibility of breast-feeding.
Questions to ask to probe for potential problems
In addition to monitoring growth, there are a number of questions a practitioner may ask to clarify whether a referral for further assessment would be helpful. The physician is able to ask these questions in such a way as to avoid alarming parents whose children are falling within the typical behaviors of an infant or toddler.
Was your baby born prematurely?
Parents may not consider feeding skills as a developmental task. As such, they may not adjust for their baby’s prematurity when considering feedings. All feeding transitions (to cereals, baby foods, finger foods, and finally textured table foods) should be considered according to corrected age, and yet many parents introduce solids early.
Their child’s lack of skill may alarm and/or frustrate a parent, leading to increased mealtime struggles. In this case, reminding parents to use corrected age may be the only intervention required, decreasing the possibility that the child will begin to reject solid foods due to negative experiences that result from difficulty tolerating the physical requirements of eating.
How is your baby’s appetite?
In the first 3 months (corrected age), the infant should solidify their waking, sleeping, and eating schedules. Demanding for feedings is a learned behavior. The infant cries when hungry, the parent feeds the child, the child is satisfied and comfortable, and, therefore, the behavior of signaling hunger is reinforced. Feeding problems often interfere with this learning, as the infant may experience pain or fatigue with eating, which effectively punishes them for demanding for the feeding. Infants effectively learn to ignore their hunger for long periods of time.
Do you do anything special to help your child eat?
Parents may have been taught to hold their preterm infant in a special way (eg, holding their infant in a side-lying position). If they respond with unusual things (eg, walking around, putting their child into a semisleep state to get more volume in from a bottle, playing with toys at the table), they are typically distracting their infant from learning about eating. Infants who need distractions to eat are often communicating that eating is not intrinsically enjoyable. Any need for distractions or rewards to eat sufficient volumes or variety should be explored further.
Does your baby have problems with sucking, swallowing, choking?
Occasional difficulties with coordinating sucking, swallowing, and breathing are not uncommon in infants under a month of age. The frequency and the severity are key to determining whether the child’s swallowing should be evaluated. A history of frequent respiratory illnesses may also indicate a problem with swallowing.
How long does it take to feed your baby?
Infants with feeding problems often take longer to feed than typical infants, as has already been discussed. Typical feeding duration is 20 to 25 minutes. Eating for less than 5 to 7 minutes each time, or for longer than 30 minutes each time, is an atypical behavior, but not necessarily a problem. Weight gain patterns along with duration of eating for less than 5 to 7 minutes may help determine whether the infant is not eating enough, or is eating enough and doing so with very good efficiency. Even in the face of sufficient weight gain, mealtimes lasting longer than 30 minutes may indicate mealtime power struggles or skill deficits that will likely worsen over time if not addressed.
How often does your baby eat? Does your baby have a predictable feeding schedule?
Infants generally eat every 1.5 to 3 hours in the first 3 months (corrected). However, infants in the NICU may have been fed on an every 3- to 4-hour schedule. If endurance is an issue, feeding every 4 hours may require the infant to take unattainable volumes across a 24-hour day.
Are feeding times for you usually relaxed and comfortable, or stressful? Does your baby enjoy eating? Do you enjoy feeding your baby?
Feeding an infant should be a time of relaxation and a joy for parents. The majority of time spent while an infant is awake is spent feeding in the first year of life. If families are dreading the task, or the infant is unhappy or uncomfortable, feedings often continue to deteriorate as the infant matures out of reflexive sucking and into volitional eating.
Resources for parental information
The P.O.P.S.I.C.L.E. Center (Parent Organized Partnerships Supporting Infants and Children Learning to Eat)
Their mission is “to provide educational tools and resources that serve the needs of infants and children with feeding difficulties, their families, and the professionals who care for them.”
The P.O.P.S.I.C.L.E. Center Infant and Child Feeding Questionnaire is designed to assist parents and medical professionals in identifying potential feeding issues, thus creating an opportunity for further assessment and effective treatment.
Upon completion of a brief questionnaire, parents receive a printable summary to discuss with their child’s physician. The printout is to be used as a guide to discuss possible areas of concern for further exploration.
There are multiple questionnaires covering ages, birth through age 3, and each interactive questionnaire is automatically adjusted for premature birth when the caregiver enters gestational age at birth. Each question provides developmental guidance regarding typical feeding behaviors for the age range in question, and identifies potential areas of concern that should be brought to the attention of the child’s physician.
This interactive questionnaire is available on the Web site www.popsicle.org.
Early Intervention Program or Special Education
For those children suspected of needing a more professional evaluation of their development, Federal law (the Individuals with Disabilities Education Act, IDEA) requires all states to have a system to ensure that all children who are in need of early intervention or special education services are located, identified, and referred.
While feeding problems are not universally recognized as a developmental problem, many states are acknowledging that skill deficits underlie many of the difficulties parents face in feeding their child. Children must meet eligibility guidelines according to the IDEA.
States have different eligibility guidelines for their Early Intervention Program and Special Education services. In addition to children with disabilities, some states have elected to provide early intervention services for infants and toddlers who are at risk of developmental delay and their families, to better identify emerging areas of concern. Parents may contact their state representative to get information on how to get a free evaluation from a qualified professional.
A Web site listing all 50 states of the United States, with links to all of the state coordinators who can direct parents to the resources in their area, is available at the time of this printing, at http://www.nectac.org/contact/Ptccoord.asp.
Time periods of greatest risk for developing feeding problems
Preterm infants should have their growth parameters and feeding skills evaluated using corrected age. As outlined, feeding skills of preterm infants tend to lag behind those of term infants, even after correcting for prematurity.
The times of most difficulty appear to be around times of transitions from reflexive to volitional eating skills (approximately 3 months’ corrected age), and across food textures.
Inability to transition to cups and utensils may also be an area of concern.
Specifically, after correcting for prematurity, particular care should be paid around the transition to solids (6 months), finger foods (9 months), table foods (12 months), cup drinking (17 months), off baby foods (12 months), and off bottle-feeding (18 months).
Parental guidance
There are general strategies that may help a family during mealtimes to encourage a child to become a healthy eater.
Parents should eat with their child as much as possible, and role-model good eating behaviors as well as show acceptance to a wide variety of foods.
Mealtimes should be structured and occur frequently throughout the day to allow a child to have multiple opportunities for exposure to a variety of foods, as well as to meet caloric needs.
Young children should be allowed to touch and explore their foods—especially when they are not proficient with utensils. This exploration allows the child to better understand the sensory properties of the foods.
Parents should be encouraged to support their child’s emerging sense of self. The parent can choose foods that are palatable and nutritious across a wide variety of nutrition categories, while allowing the child to determine which, and how much, food to eat.
Outcomes
Breast-feeding outcomes
Differences in prevalence rates in breast-feeding during and after discharge from the NICU exist across different countries and cultures.
Sweden routinely presents the highest breast-feeding rates in preterm infants at the time of discharge, reporting that 92% of preterm infants discharged with some level of breast-feeding. Exclusive breast-feeding was most prevalent in the late preterm group (32 to 36 weeks at birth), with 56% of this cohort achieving full breast-feeding, compared with 35% to 38% in the early preterm groups.
US rates of initiation of breast-feeding are lower. 78% of mothers initiated breast milk feeds, but only 52% of the infants ever breast-fed in the NICU.
Across all countries for which data are available, prevalence rates of breast-feeding decline across the first year of life. This is especially true among premature infants. In the United States, prevalence rates drop to 3% to 16% by 3 months of age. Exclusive breast-feeding rates decline to 5% in the youngest group (born less than 32 weeks’ gestation) at 6 months.
Bottle-feeding outcomes
The majority of healthy preterm infants are discharged to their home successfully nipple feeding well enough to avoid needing supplemental tube feedings.
Fewer than 1% of infants born between 32 and 36 weeks’ GA were discharged with the need for supplemental tube feeding.
Among all infants born at less than 36 weeks, 8.6% are discharged home on gastrostomy-tube feedings.
Extremely early born infants continue to have immature feeding patterns at term compared to either later born preterm infants or term infants.
Earlier born infants have a higher prevalence of feeding difficulty, and take longer to achieve full oral feedings.
The highest prevalence of infants needing a gastrostomy tube (14%) is seen in the youngest group (GA <28 weeks at birth), with 10% requiring gastrostomy feeding in infants born between 28 and <32 weeks. Seven percent of those infants born between 32 and <36 weeks’ gestational age also needed gastrostomy feeding.
Medical comorbidities are highly correlated with a delay in feeding initiation, feeding abilities, and length of stay.
Solid feeding outcomes
20% of parents reported their child’s eating in the first year after birth as very poor and 78% of parents reported the quality of their child’s diet was a major concern; however, only 8% identified skill development as an important issue. This disconnect between understanding that skill deficits underlie feeding problems leads to a delay in parents raising concerns regarding their child’s eating habits as the parents assume the problem is a “behavioral” one.
Feeding problems last throughout childhood for some, especially those born very prematurely.
Eating problems are significantly more prevalent in these children at age 6 compared to term children at the same age. Frequent problems include spitting up/vomiting and long durations of mealtimes.
Summary of oral feeding progression in the preterm infant
Preterm infants undergo neurobehavioral developmental changes that include beginning to eat orally, a sophisticated and complex set of skills. The rudimentary basics for successful eating are typically in place at the time of discharge from the NICU. However, infants need to continue developing their eating skills to successfully transition to a wide variety of age-appropriate foods. Between birth and 12 months of age, infants move from a fluid diet to a pureed diet and finally onto a textured finger- and table-food diet. By age 3, children are eating a diet consisting of a full range of foods. Developmentally, infants must negotiate these changing nutrition sources by developing motor, oral-motor, and sensory skills, becoming more independent in eating with each transition. Between 3 and 4 months of age, infants undergo a shift in feeding skills from a reflexively driven sucking action to a volitional feeding pattern. Infant diets begin to include baby cereals and baby foods by 6 months of age, requiring a different oral-motor pattern of suckling than was necessary for breast- and bottle-feeding. Between 6 and 12 months of age, infants transition from fluid and baby foods to finger foods and textured table foods. These transitions require different (1) oral-motor skills (sucking to spoon feeding to chewing), (2) motor skills (being held in the arms of the caregiver, to sitting in a semireclining position, to an upright sitting position with finger feeding and utensil use), and (3) interaction skills (cuddling to reciprocal feeding interactions). Additionally, foods that are offered become more complex from a sensory standpoint, with increased flavors, colors, shapes, textures, and tastes of foods. The physician can use early weight-for-age shifting as well as thoughtful queries regarding mealtime skills and behaviors, to identify infants who might benefit from early intervention, prior to the infant developing potentially inappropriate compensatory behaviors and actions.
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