Health Information and Tools >  Oral Feeding Your Preterm Newborn or Infant with Challenges: Steps to Safe and Enjoyable Feeding

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Breastfeeding is the best way to feed babies.

When breastfeeding is the mother’s goal, it is important that the breast be the first feeding experience for babies.

Babies who are born premature benefit greatly from breastmilk and breastfeeding.

However, premature babies may not be able to take enough from the breast or may need high calories to grow well.

In these situations, alternate feeding methods, such as tube feeding or bottle feeding, may be necessary to augment breastfeeding.

Learning to drink can be challenging for some babies. 

This video focuses on helping parents support their baby as they learn to feed by breast or bottle but does not address all breastfeeding strategies. 

Additional breastfeeding resources are available to families, such as online videos, lactation consultants, or community clinics. Ask your NICU nurse.

Feeding by mouth or oral feeding is a skill that many babies need help to learn. 

Sometimes babies can feed well by mouth for a few minutes but not the entire feeding.

Oral feeding refers to all feedings by mouth, including breast and bottle feeding.

Every baby is unique. Some babies develop breast or bottle feeding skills quickly and other babies will still need some help to drink enough milk and grow 
well once they go home from the hospital.

Learning to feed takes practice.

Like learning to walk or talk, learning to eat is a developmental skill.

As such it relies on building base skills such as waking regularly, maintaining breathing, learning to suck, and building stamina.

It is important to start slow and follow your baby’s cues at every step of the way.

Your baby will show you what he or she is ready for.

Babies need a positive feeding experience while they are practicing feeding skills.

As feeding skills improve, the amount your baby will be able to take by mouth will also improve.

Tube feedings may also be used to make sure your baby is growing well while your baby is building skills.

Together with the healthcare providers looking after your baby, an individualized feeding plan can be made to help your baby succeed at feeding.

This video will help you recognize your baby’s feeding strengths and stress cues. 

The video will give you information and tips to help you help your baby develop oral feeding skills.

There are many stages of oral feeding.

This video will teach you how to read your baby’s cues, which will help you to know what stage your baby is at.

You will also learn strategies to help support your baby’s feeding skills.

Feeding is a complex skill.

Your baby will need to learn to breathe, suck, and then swallow to be able to breast or bottle feed.

The stages of oral feeding describe how babies develop skills in breathing, sucking, and swallowing.
[Stages of oral feeding]

Learning to orally feed is a stepwise journey.

Your baby needs to build stamina and endurance with each step before moving onto the next one.

Steps along the way may include:

Pre-feeding. Your baby is learning to breathe smoothly and starting to wake on his own. He is getting stronger to be able to keep breathing when being held or with caregiving. 

Sucking and breathing practice without milk. This is where your baby is practicing sucking on a nipple without milk while still breathing well. Your baby is not ready to suck, swallow milk, and breathe. 

Introduction of milk is divided into 3 areas:

It starts with tastes of milk. You baby is staring to learn to suck, swallow very small amounts of milk, and breathe. 

Practicing drinking milk is where your baby will start to have small amounts of milk by breast or bottle and learn to have more and more. 

And then moving to full feeds by mouth. This is where your baby transitions to full breast or bottle feeding by mouth. This can take some time. It takes a lot of energy and skill to take all feeds by mouth. You can help your baby by being patient. 

The stage your baby is at is based on her feeding skills and ability and not dependent upon her gestational age. 

A healthy premature baby born at 33 weeks may be able to reach full oral feedings before a baby born at term with medical problems. 

Babies may need to go back to a previous stage while they are building skill and endurance. 

This can be for many reasons including illness and surgery. 

Take this baby for example. He is showing us many stress cues including heavy breathing and wide eyes, which is telling us it is not safe to orally feed him at this time. 

Even if your baby has reached full oral feeding, he may continue to need tube feedings if he is unable to demonstrate safe, effective, and pleasurable feeding. 

[Pre-feeding – learning to breathe]

If your baby is very medically fragile, your baby will not be ready to have sucking practice or oral feeding. 

In this stage, she is learning to breathe. This is called the pre-feeding stage.

However, during this time, you are helping your baby to get ready to orally feed by being at your baby’s bedside and letting your baby experience your gentle touch and the sound of your voice.

Perhaps you were supplying breastmilk to help your baby grow.

When babies experience kangaroo care, they respond to their parent’s touch, breathe more regularly, and fall into a restful sleep. This helps their brains to grow and develop.

[Sucking and breathing practice without milk]

Sucking and breathing practice without milk is a very important stage. 

At this stage, your baby is learning to suck and breathe without being offered milk to swallow. 

During this time, your baby will have tube feedings in order to grow.

There are many different ways to do this practice, like:
sucking on a soother, or
nuzzling at a pumped breast

Once your baby has learned to breathe as well as she can suck, she will be ready to move to the next stage. 

[Tastes of milk]

Now your baby is ready to learn to swallow a very small amount of milk while practicing breathing and sucking.

Some babies need a long time to learn these skills.

Your baby may start to learn to suck and swallow by being offered a very small taste of milk:
either from licking milk from your breast
dipping a soother in milk, or
by offering drops from a small syringe onto the soother while your baby sucks on the soother.

Whatever way you are offering taste, give your baby time to get ready for the next drop. 

Moving forward, your baby may be ready for small feedings by breast or bottle. 

This baby is put to the pumped breast to make sure she is not getting too much milk at once.

This baby is being offered a small amount of milk in his bottle.

He needs lots of time between sucks to catch up with swallowing and breathing. 

You can help him by watching carefully and giving breaks when needed. 

He is learning and needs practice with small amounts. 

He will not yet be able to drink a lot, but he is learning that feeding feels good. 

At this stage your baby takes breaks and needs this rest. 

When you tap, jiggle, or spin the bottle while he is catching his breath, you interrupt this break.

Rest the nipple on his lower lip and wait for him to open his mouth to let you know that he is ready to continue. 

[Practicing drinking milk]

Now your baby is waking for feedings and showing he is hungry by fussing, smacking his lips, and sucking his hands. 

Most babies spend a lot of time practicing drinking milk and slowly will drink more and more at breast or bottle.

Though your baby’s skills are improving, he may not have enough energy to finish a full feeding yet. 

Your baby may show you he is tiring by slowing down and showing signs that he is done feeding.

Notice how this nurse recognized that this baby was done with feeding, and helped his mother know it was time to stop. 

We will show you later how to recognize these important cues.

Tube feedings will still be needed to help your baby get the nutrition she needs to grow and be healthy while she is learning to suck, swallow, and breathe.

The focus is to make each feeding experience safe, enjoyable, and just feels good.

[Moving to full feeds by mouth]

Your baby has had lots of practice and is now able to suck, swallow, and breathe well. 

Your baby is waking more often on her own and asking to feed. 

She is staying longer at the breast or bottle and drinking more milk.

Sometimes, your baby may show hunger cues after 3 hours and, at other times, after 2. 

She may ask for more milk at certain times of the day than others, but is starting to take enough milk in a day to grow well. 

The success of breastfeeding and the amount offered at bottle feedings will be based on your baby’s feeding cues and growth over a longer period of time. 

How often your baby is weighed will vary depending on how well your baby is growing.

[How does your baby tell you he/she is ready to feed?]

Babies tell us they are ready to feed by showing us they can become very good at sucking and breathing, like this baby is doing on the soother.

When this baby is offered the milk, watch how he has a calm body, latches well on the nipple, and coordinates his sucking, swallowing, and breathing 
during the feeding. 

He is swaddled, which keeps his body tucked so he can focus on feeding.

After a pause, he continues to feed.

This baby is waking for his feeding.

He shows us he is hungry by sucking on his hand and moving towards his mother’s breast. 

He has a wide-open mouth to latch onto the breast. 

His sucking pattern is smooth, and he has a good suck, swallow, and breathing coordination.

After a pause, he continues to suck. 

He stays calm and keeps his body tucked throughout the feeding, showing he can maintain the strength in his muscles. 

He then falls asleep as he finishes his feeding. 

[How your baby tells you he/she is not ready to feed]

Let’s talk about how babies tell us they are not ready to feed. 

Things can change really quickly.

He may feed well to start with and then start to have difficulty. 

You will need to give your baby a break.

He may then show you he is ready to continue or he may be done.

There are a number of cues the babies show us.

Some cues are easy to see, while others can be easily missed.

Your baby may feed well for a while, but then gets tired and falls asleep part way through the feeding.

When this happens, your baby has had enough. The rest of the feed may need to be given by tube.

Squirming is one of the first signs your baby gives when she is having trouble keeping up with swallowing.

She will need a break and may need help with slowing the flow of milk.

Your baby may use hand signals to tell you she is in trouble.

If you see these signals while feeding your baby, your baby needs a break from feeding to recover. 

This baby is raising her finger and may be saying “Wait a minute, I need some time to get used to the nipple in my mouth before I can start sucking.”

Babies may show us they need a break from sucking by splaying their fingers or making a “stop” signal with their hand.

Your baby may need time to organize sucking and breathing, get used to the flow of the milk, and take some recovery breaths before they can continue.

Just as you show distress with your face, so can your baby. 

In the next scene, the baby is showing he is becoming more stressed with feeding.

Look how his eyes get bigger as he gets into trouble. He has a “worried” look.

In addition to his fast breathing, this baby furrows his eyebrows, looks worried, and then starts to blink. See how his eyes widen.

Yawning is another way babies tell us they may be stressed.

If your baby has hiccups, you may need to stop and wait for him settle before continuing.

Your baby shows you she is having trouble keeping up with swallowing by gulping and letting milk trickle from her mouth as she sucks.

Babies will try to open their mouth and let some milk out when they can’t keep up with swallowing.

They are telling us to stop and give them a chance to swallow.

A baby may cough when the milk goes the wrong way.

This is another sign that the baby is having trouble keeping up with swallowing.

Look how hard this baby is working at breathing.

She cannot work on sucking and swallowing because she is struggling to breathe. 

Breathing is more important to this baby than drinking right now. This feeding needs to stop. 

Look at the way this baby’s throat dips in while she breathes.

This is called a “tracheal tug”.

This is a sign that your baby is working very, very hard to breathe and needs a break.

If this continues, the baby is telling you she is not ready to feed.

If she is working too hard to breathe, she may be using more calories to feed and will not grow well.

Sometimes babies “shut down” because the feeding is too stressful.

This baby is struggling to feed and is overwhelmed with all he is experiencing.

He is choking on the milk. 

He is working hard at breathing.

He has a good suck but gets too much milk with each suck and can’t keep up with the swallowing.

This baby is telling you he cannot continue, and the feeding must stop.

[Things you can do to help your baby feed]

Let’s have a look at some ways you can help your baby have a positive feeding experience, while building the skills needed for full oral feeding.

This baby is positioned lying on her side to give her more control of the milk in her mouth and prevent it from pooling at the back of her throat. 

If you have not used side-lying, it may seem unusual at first. 

However, this is the position babies are in when they are breastfed, so it, too, is a natural position for feeding. 

It is important that the baby is supported, with his head in line with his body. 

The ears need to be in line with the shoulders and hips. 

With the head and shoulders higher than the hips, the milk will flow easier into the stomach. 

The baby must feel supported all along her body, so she does not feel that she is hanging in space.

Place a pillow underneath her to support all her body. 

Good positioning helps babies to breathe easier. 

Next, look at the arm position.

Both arms need to be supported forward.

Pay attention to where the top arm is, so that it is not falling back.

Most babies will not feed well if they feel they are falling.

Babies need to have good support of their body to be able to focus on eating.

Look how well this mother is bundling her baby for feeding.

Her baby stops squirming and is comfortable and ready to feed.

Most babies need a slow-flow nipple for bottle-feeding.

Check the flow rate after warming the bottle.

Warming the bottle can cause milk to flow quickly. 

If the nipple is spraying, unscrew the cap to relieve the pressure before offering the bottle to your baby.

While babies are learning to eat, they often struggle with faster flow by breast or bottle. 

​If you have a strong milk let-down (milk releasing from the ducts in your breasts), you may try the laid-back nursing position. 

Or possibly use a nipple shield to help your baby with the faster flow. 

In some cases, you may need to pump for a few minutes before putting your baby to the breast. 

Your lactation consultant can help you find the optimal position and techniques to help control the flow.

[Pacing with a bottle]

Early stress cues often tell us that your baby needs help with pacing during a feed.

Pacing is a strategy that helps your baby to breathe more easily during the feeding.

Babies with a strong suck often get into trouble with the first suck.

They get a big mouthful and don’t stop to swallow and take a breath before the next suck. 

They are often hungry and vigorously sucking at this time.

Their body is giving mixed messages: “Hurry up, I am hungry” and “Slow down. I can’t suck, swallow, and breathe this quickly.” 

Pacing is easy to do. When pacing is done correctly, the feeding goes smoothly. 

Even though you are imposing breaks, the overall feeding time is not longer.

When babies need pacing, and we help them to pace, they can feed longer before tiring.

Often, the amount they take improves quite a lot.

To pace, remove the nipple from the baby’s mouth and rest it on the baby’s lip.

Tipping the bottle is not enough for most babies with suck/swallow/breathing incoordination.

While the nipple is in their mouth, they don’t always swallow or take a good recovery breath.

When the next suck comes, the previous swallow has not yet cleared their mouth.

Often, the baby just continues to suck air if the nipple is tipped down without being removed from the mouth.

Watch for your baby to cue you by opening her mouth, inviting you to place the nipple back in her mouth. 

Do not rush your baby by jiggling or spinning the nipple.

The baby will suck when the nipple is moved within the mouth, even when they are not ready. 

They need to stop sucking to take extra swallows and breaths. 

Wait for her to tell you she is ready to receive the nipple. 

You may worry about removing the bottle because in the past, when the bottle was removed, your baby didn’t continue feeding.

This may have been because she was not putting in breaths soon enough or taking deep enough breaths.

When she finally paused, she was too tired and wanted to quit feeding.

A baby may also not continue with feeding if pacing is not coordinated. 

It is important to pay attention and when your baby opens his mouth, be ready to put the nipple back in his mouth.

This baby gets a big mouthful of milk each time he sucks. 

With the nipple removed, he is able to take several swallows to clear his mouth and is able to take several breaths before he is ready to continue. 

He opens his mouth to let us know he is ready to have the nipple back in his mouth.

Mom and babe are in good rhythm together.

He does not get frustrated, because his mother is responding to his cues.

When she removes the nipple, she rests it on his lip. 

Pacing does not work when the nipple is removed too far from the baby’s mouth. 

When the nipple is too far away, the baby is ready to have the nipple back in his mouth, but the parent is not ready.

As the feeding continues, the baby sucks slower. 

His coordination of sucking, swallowing, and breathing has improved. 

He can now suck a little longer before he needs to be paced.

He is now being paced after every 6 to 8 sucks.

Pacing did not make the feeding take longer.

He took 15 minutes instead of one hour to finish a bottle. 

With pacing, his feeding skills were better coordinated, and he had more energy because he took more frequent and deeper breaths throughout the 

[Pacing at the breast]

If your baby is still drinking too quickly, even after trying other strategies such as laid-back nursing, a nipple shield, and a partially pumped breast, some 
babies may need to be paced at the breast. 

They have a strong latch and get a lot of milk with each suck. 

They need help to take breaks in order to swallow and breathe. 

To pace at the breast, place your finger at the corner of your baby’s mouth.

Gently break the seal. 

Remove your baby slightly away from the breast. 

After your baby has swallowed and taken a recovery breath, your baby will cue you by opening his mouth when he is ready to continue.

This baby has some trouble with suck/swallow/breathing coordination. 

He has a very strong suck and has trouble keeping up with the swallowing and breathing.

His mother gently places her finger at the corner of his mouth to break the seal and release his latch. 

He swallows several times and takes extra breaths before he lets his mother know that he is ready to continue by opening his mouth.

Watch how hard he is working to breathe. 

He can manage 5 or 6 sucks, followed by a long rest break. 

His rest breaks are longer than his sucking burst, which tells us he needs a lot of time to recover between sucking bursts. 

His mother watches his cues closely. 

His cues and her responses are working well together. 

As his coordination improves, he can now suck for 8 to 10 sucks before needing to be paced.

His pauses between sucking bursts is shorter. 

Here, his mother is interrupting his need for taking a rest by trying to get him to latch when he is not ready.

We asked her to wait until he cues her by opening his mouth to say he is ready to continue. 

This is the first time that pacing was done during the breastfeeding for this baby. 

He had his best feed ever, because he was paced and did not tire out too quickly. 

[Tube feeding]

Tube feedings are meals, too. 

The stomach is about the same size whether your baby’s feedings are by mouth or by tube. 

A tube feeding should take about the same time as the feeding would take if it could be given by mouth.

Some babies receive oral gastric (or OG) tube feedings, which means the tube passes through the mouth to the stomach.

Other babies receive nasal gastric (or NG) feedings, which means the tube passes through the nose to the stomach.

Whenever possible, hold your baby during tube feedings. 

Position your baby cradled in your arms with the head and chest higher than the legs to help them digest and prevent spitting up. 

When babies squirm during tube feeding, they may be telling us that the feeding is going in too quickly and they are uncomfortable. 

Sometimes, babies may squirm during tube feedings because they are feeling full.

You can help by slowing or stopping the tube feeding for a while to allow the stomach to empty a little. 

This can be done by lowering the syringe and pinching the tube. 

Babies benefit from burp breaks during and after tube feeding. 

Some babies are very sensitive to the amount and the speed of tube feeding. 

Notice how this baby is lying flat for his tube feeding. Lying flat or going in too quickly can cause him to spit up.

If your baby gags or spits with the tube feeding, your baby may benefit from longer or more frequent breaks during the tube feeding and being held upright. 

Burping is important. 

Without burp breaks, your baby is more likely to spit up or feel uncomfortable during or after a feeding. 

Sometimes a baby feels full because they have air in their stomach and may stop feeding, but after a burp, they are ready to eat some more.

You can hold your baby in a sitting position. Support your baby’s head and watch that your baby is breathing well and has good colour.

See how well this baby is positioned. 

Make sure your baby is not bent over too much, since this puts pressure on the stomach, which may make your baby spit up. 

You can also burp your baby by placing her on your shoulder as long as you position your baby so you can keep an eye on her.

Move your baby slowly in and out of the burping position.

Moving quickly may make them uncomfortable and spit up. 

[You and your baby’s feeding journey]

Every baby is unique. Some babies develop breast or bottle feeding skills quickly and others will continue to need some help once they go home from the 

Some babies may keep up with oral feedings while they are in hospital but cannot keep up with the higher volumes needed for growth once they go home.

Some babies will need tube feedings at home to help them grow until they can take all their feedings by mouth. 

Remember to burp your baby during the tube feeding.

All babies who have gone home from the hospital are still developing their feeding skills. 

They will continue to need a slow-flow nipple, pacing, and be positioned side-lying for bottle feeding. 

For breastfeeding, they will continue to benefit from the positions and strategies you used in hospital. 

There are lactation consultants in the community to help you with your breastfeeding journey once you have gone home. 

You and your baby are on a feeding journey.

By watching your baby’s cues, you will know when your baby is ready to feed and when your baby is telling you they cannot orally feed right now. 

You also know ways to help your baby learn to feed. 

You support your baby by being ready to feed when your baby is showing hunger cues, holding your baby close and bundling in a blanket for bottle feeding, 
keeping their head and chest higher than his legs, noticing when he needs a break, pacing when he is very eager, stopping when he’s finished, and following 
her lead at each point in the feed. 

In this way, you are building a feeding relationship built on trust.

Your baby learns to trust that you will always follow her lead and help make feeding safe and pleasurable.

He will continue to develop strong feeding skills and learn that feeding feels good.

[Parent 1] “3 months in the hospital just seems like forever. Yeah, it’s long. It’s hard, because I thought the day was never going to come.”

[Parent 2] “They told us she was coming home. Wow, we were excited. I was nervous: ‘Oh my god, are we ready?’”

[Parent 1]: “Yeah, the day they said I could take her home, I was in there and they were all saying: ‘Bye’ and I was like: ‘Bye!’ and I was out the door. Like: ‘It’s 
time to go home!’”

[Parent 3] “So she’s doing really good. She’s a very happy baby.”

[Parent 1] “Know there is hope. That you will go home.”