FEEDING FRENZY!

It's simple to us. We feel hungry. We grab a bite and eat it. 

We may take it for granted, but for a newborn, eating is a huge accomplishment! 

We see it happen so naturally in newborns, it seems simple. Newborn puppies find their mama’s teat before they can open their eyes, latch on and feed instinctively. Newborn humans typically need to be fed within the first hour of birth. Off they go, it's a 

FEEDING FRENZY! 

Thanks to www.creativecommons.org

If you're lucky, all will go well with those mealtimes. You'll be looking for ways to make meaningful, bonding, quality times. Here are some suggestions to support fun during these mealtime frenzies:

• Set the feeding area up for comfort! Bring a pillow or two nearby in case you need a quick adjustment. Don’t forget the remote control, a drink and perhaps a snack for yourself. Create a place you can prop your feet up.

• Set the mood with appropriate lighting and sound. Music is preferable to television, as it frees you to watch baby and respond to her signs during the meal. However, this is not the time to play blaring rap or heavy metal music. Music with a steady rhythm is shown to be calming, whereas irregular rhythm (like jazz) stimulates the nervous system. If you do watch television, be aware of what you’re watching while feeding your baby. If the show is suspenseful (yes, baby feels your body tension) or even just too loud, baby won’t be able to maintain the right alertness level. Perhaps you think baby sleeps through these loud or scary shows, so it doesn’t matter. Newborns will fall asleep if they are OVER-AROUSED as easily  as if they are tired. You don’t want to over-arouse baby, and you don’t want to put baby to sleep during mealtime. Adjust the environment to find the just-right stimulation that supports baby’s ability to calmly complete mealtime.

• If you’re inclined to hum or sing, go ahead! Mealtime is a good time to do the things that support your happiness and help baby feel happy, too. Watch baby’s body and face for signs of contentment. Enjoy them together. A recent scientific study found that mother's voice helps normalize (ie., modulate) baby's arousal state. If baby's stressed, it calms. If baby's too groggy, it alerts. Find this study here.

• Interact with eye contact and facial expression as suits the two of you. At first, newborns cannot establish eye to eye gaze, but they may try to focus on your face briefly. This develops readily in the first couple of months, so it won’t be long until baby wants to engage with you eye to eye. These times can really touch your heart. Smiles start to be shared, as do other facial expressions, even during feeding. These back and forth playful exchanges of love and contentment are super-healthy—for both of you! If you're uncomfortable with eye contact, now is the time to get some practice for yourself! Baby won't judge you, so go ahead and give it a try. 

Thanks to www.creativecommons.org
Sweet baby gazing time!

But sometimes things aren't so simple. If you're having any trouble with mealtime, read on. . . 

Photo courtesy of www.milkmatters.org.uk

Babies need plenty of nutrition for all the growing they're doing, so if there's a problem feeding, they need your help. You may be surprised to find that feeding is an extremely complex task, requiring a delicate balance of structure and function on both the feeder and the feedee’s parts. If one small thing goes awry, the whole process can be thrown off, with potentially disastrous results.

Think about it. 

The feeder (usually the mother) must be equipped with a nutritious and delicious product that is the proper consistency and temperature. She must have a method to administer this delightful product that guides it into the baby with an appropriate rate of flow and frequency, while also providing adequate physical comfort, so both mother and infant can comfortably sustain the mealtime without fatigue and distress.

On the infant’s side, baby must be supported in a position that permits comfort so he can focus on the primary task. He must be able to coordinate and sustain a rhythmic pattern of sucks and swallows, and breaks to breathe without any fluid going down “the wrong way,” as we say. The baby’s internal organs must be strong and mature enough to keep the food where it should be for proper absorption.

The swallow process itself is incredibly complex. We take it for granted—until something out of the norm happens. If you’ve ever experienced choking or gagging; something “going down the wrong pipe,” then you know what I mean. Suddenly, nothing else matters! All mealtime activities and conversations stop until the bolus is cleared and the airway is safe.

To safely swallow, the mouth forms a vacuum seal. Lips must seal tightly, whether against one another or around a straw. . . or, in the case of a baby, around a nipple. 

Try taking a sip of water and swallowing it with your lips NOT sealed. What happens? How does it feel—physically? -emotionally?

As the lips seal, the bolus must move from the front and sides of the mouth to the back of the tongue. Yes, right there in the “gag” area, WITHOUT initiating the gag response. 

Find that spot. Touch the “gag” area of your tongue with your finger. It is right in the middle and to the back of your tongue. It is just before the entry way to the throat. It is there to help you automatically avoid swallowing things that aren’t meant to be swallowed. It is also designed to permit safe swallowing when all the pieces of the puzzle are just right. 

When the lips seal and the tongue (a muscle that, when evenlyinnervated, shapes and moves properly to guide the bolus) does its job, the bolus is smoothly pressed to the back and top of the mouth, where that vacuum seal completes the pushing of the bolus past the mouth and down the hatch. This action only works if the lips can seal and the tongue can push up against the roof of the mouth, also known as the palate.

Try it! Take another sip of water and hold it in your mouth. Now focus on trying to swallow it without letting your tongue touch the roof of your mouth. Are you able? What did it take? How does it feel trying—physically? –emotionally?

(Here's a video borrowed from YouTube showing a normal infant swallow study)

There’s even more that goes into getting the food past the mouth. There’s hunger and desire to eat. There’s alertness on the part of the feeder. There’s aroma, taste, temperature, and positioning. 

It’s pretty easy to imagine how uncomfortable you would be if someone tried to feed you when you weren’t hungry, or when you were sleeping, or if the food smelled bad (or didn’t smell at all),  tasted nasty, or was too hot or cold. The last one, though—positioning—we tend not to consider. As adults, we sit up to eat. If we can’t sit up, we at least need to tilt our head up enough to safely swallow. This position allows our oral structures to overpower gravity so we can properly control and guide the bolus to the back of the mouth without overdoing the amount or eliciting a gag response.

Infants have a differently shaped palate. Actually, there are many things different about a newborn's oral structure, but we'll stick to the basics. The shape of the roof of their mouth doesn’t permit upright positioning to swallow; not until they’ve achieved motor control in the upright position. Their head, neck and torso strength not enough to overcome gravity, they need physical support during feeding so they can focus on the difficult job of coordinating lips, tongue and swallow musculature without choking or gagging. The nipple provides assistance by placing the milk toward the back of the mouth, and its size lets baby’s lips seal around it with minimal effort. The reclined position, with head, shoulders and torso supported so the chin can tuck slightly in, facilitates ease of suck and swallow control. The chin tuck position is still important as adults.

Try this: take a sip of water and hold it in your mouth. Try to swallow with your chin jutted out (pushed forward). Can you do it? Try it with your head tilted to one side, and to the back. All positions EXCEPT midline with chin tuck make it very difficult to swallow, right?!?

If abnormalities of muscle tone in the tongue, lips or shape of the palate exist, professional treatment (ie, physician, and speech or occupational therapist specializing in feeding) is warranted.

The third part of this “simple” task of feeding is coordinating the need to breathe while feeding. Did you know that the tube that takes the food to the stomach is shared (partially) with the airway passage? A junction with folds and a flap controls which way food, fluid and air can go. It opens to permit air to the lungs and  closes to block the airway and let food and liquid pass to the stomach. If there is a malfunction at this junction, permitting leakage into the lungs, we have aspiration. The lungs are not made for food or water. They do their best to expel anything wrongly placed there, but even the tiniest amounts can lead to pneumonia. 

If baby frequently gags or coughs when feeding, we must closely attend to all the factors involved rather than ignore or minimize it. Just as conversation at the table stops when someone chokes or gags, so must mama stop and attend if baby chokes. Change her position to move her upright and forward. Raise one of her arms. Clap her back as you would when burping her. Attending to the need can prevent disaster. Frequent choking or coughing during feeds should alert you to consider changes in baby’s feeding position, the consistency (ie., viscosity) of the fluid and the flow rate of the nipple. Slower flow rate and thicker fluid may be all that is needed. If baby’s coordination of sucks/swallows and breathing seems problematic, provide external pacing to help baby take a break to breathe. External pacing is simply pulling the nipple back so baby takes a brief break to swallow and breathe. Click here to read more on the exact details of this pattern and process.

Of importance to note is not all babies actively cough when fluid is aspirated. Some may have what is called “silent aspiration,” but typically we can notice signs of discomfort when this happens. Baby may squirm, grimace, and turn away from feeding. Baby’s breathing may sound gurgly or “wet.” We MUST attend to and respond to these signs as seriously as we would to coughing. If baby develops pneumonia, this is a huge red flag! Ask your pediatrician for a swallow study, also known as videofluoroscopy. This is imaging that traces exactly what happens in all phases of baby’s swallow. It can help determine exactly what and where the problem lies, and help determine the best course of action to correct it. Early intervention can save baby’s life, and it can prevent serious feeding aversion and attachment issues down the line.

In most cases, the bolus successfully passes this junction and travels to the stomach, where the body begins to break down food for nutrients. In some infants, another problem happens here. The muscular junction at the esophagus and the stomach can be weak, permitting back-flow (along with some powerfully acidic gastric juices) into the esophagus. The esophagus is not meant to handle digestive acids. It can become quite irritated by this back-flow. Signs this is happening may include spitting up, grimacing, squirming, crying and arching the back during or after eating. Baby may start turning away from feeding. Often, you’ll notice extra gassiness and general fussiness. When these signs are noted, a visit to the pediatrician is due. 

Note loosened sphincter permitting gastric juices to splash into the esophagus. Picture from: https://www.webmd.com/heartburn-gerd/ss/slideshow-heartburn-overview

If reflux is the issue, there are several strategies you can implement prior to, or in addition to, medication.  These are often referred to as first line treatment, as medication may have side effects that can be avoided if these strategies help. They include:

• Position baby more upright during feeds (about 45 degree angle). This employs gravity to help the fluid stay in the stomach. Be sure to provide adequate head, neck, shoulder and torso support so that swallowing is still supported.
• Interrupt feeding every 1.5-2 ounces to facilitate burping. Place baby prone on your chest and shoulder rather than sitting forward on your lap. Burping with baby sitting places more pressure on the organs which can push fluid out of the stomach. Burping with baby laying on your chest and shoulder with her body straighter helps keep the fluid in the stomach.
• Try a slower flow nipple. See here for a chart of real-life flow rates for various brands. Slowing the flow and taking frequent breaks can help by giving more time for the stomach to process what it has so it doesn’t get backed up.
• Try anti-gas bottle feeders, such as Dr. Brown’s, which keep gas from getting into the fluid as baby feeds. Be sure to read and follow the instructions that come with the bottle. Don’t shake a bottle prior to feeding. This adds gas bubbles to the fluid. Swirl or gently stir instead.
• Try thicker formula or a thickening agent approved for infant use. Be sure to only thicken slightly. This is best done with doctor’s advice, and with a feeding therapist’s close supervision as you establish the best viscosity. Thickeners like rice cereal can be dangerous because they can clump and cause baby to gag or choke on clumps. Only use this if your doctor recommends it, and even then watch very closely for signs of gagging (in the mouth) or choking (in the "tube."
• HOLD baby upright for 30 minutes after meals. Laying on your chest position is optimal, according to recent research, following  the recall of supine-incline infant sleepers. If baby must lay down, lying on his left side after meals is preferable to the right. This is due to the angle of the structures; when lying on the left, food is more likely to stay in the stomach rather than being forced out.

Note in chart pictured, how fewer episodes occur in the left side position. This is from research found at this site: https://www.slideshare.net/TauhidBhuiyan1/gastroesophageal-reflux-in-preterm-neonate

If all of these are not enough to resolve the issue, consult with the pediatrician again. She may suggest drops to decrease gas, and may suggest a course of prescription medication. It is important to attend to these needs as chronic inflammation of the esophagus presents medical complications and can also lead to feeding aversions and attachment issues.

Now, with all these bases covered, feeding can progress as a happy, fun time. Bonding and attachment occur during these precious routines between caregivers and baby. Baby learns she can feel secure and loved because caregivers respond to her needs and help her thrive. With the suck, swallow, breathe pattern established and with food staying down,  mealtimes can be times for watching and listening to mommy and daddy, learning to gaze into your eyes, and exchanging love and trust.

References for the above are blended into the text. If you see a different color text, except for red and green which are used to highlight, you should be able to click on it to the source or further reading. Most photos also have clickable links to their source for more information.