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Feeding the Medically Fragile Infant

Written by Rebecca Brown, M.S., CCC-SLP, CNT 

Amy’s Story

Amy was born at 24 weeks gestational age, 16 weeks before her due date. Amy was born with her twin, but her sister did not live more than twenty-four hours after delivery. Since delivery, Amy has undergone multiple procedures, including x-rays, eye exams, head ultrasounds, and phototherapy. She was on mechanical ventilation because of her immature lungs for more than a month before being able to breathe without the assistance of the ventilator.  Amy still required supplemental oxygen through a nasal cannula in order to support her breathing. At 32 weeks, Amy began demonstrating signs of hunger, including bringing hands to mouth, opening her mouth wide, and moving her head around to search for a breast or bottle. How should the medical team approach feeding this medically fragile infant?

The role of the Speech-Language Pathologist in the NICU

Infants born prematurely are not able to safely and effectively eat by mouth until they achieve physiologic stability.  This milestone occurs around 34 weeks postmenstrual age on average.  The multi-disciplinary medical team evaluates and determines the best time for each infant to begin oral feeding during their NICU stay1.  Speech-language pathologists (SLPs) with specialty in infant feeding and swallowing development and disorders work as part of the multidisciplinary team to assist with the process of advancing the infant from gavage feedings (i.e., providing breastmilk or formula directly to the baby’s stomach through the use of a tube place through the baby’s nose) to eating by mouth. In many cases, SLPs with advanced training in developmental care are part of the infant’s NICU care team from the first day of admission.  The SLP, as part of the developmental care team, may assist with positioning the infant in a warmer, cleaning the infant’s mouth, and protecting the developing central nervous system from overwhelming stimuli (i.e., bright lights, loud noises, noxious smells, etc.)2. Typical duties the SLP may perform as part of the developmental care team may include but are not limited to:

  • Testing the infant’s reflexes in the mouth, including the ability to move the tongue side to side, biting down when the gums are offered pressure, and opening mouth in anticipation of the nipple
  • Providing the infant with an appropriately sized pacifier in order to provide positive oral experiences such as non-nutritive suckling during gavage feedings3
  • Dipping the pacifier in breastmilk or formula to allow the infant a “taste” while sucking
  • Monitoring for changes in the infant’s alertness and state during activities and care routines and providing intervention to help the infant maintain the desired alertness level as needed4,2
  • Monitoring the infant’s oxygen level, heart rate, and breathing rate (vital signs) during activities and care routines and intervening as needed to help infant maintain physiologic stability2

The SLP also facilitates family bonding and care of the infant as part of their role on the developmental support team.

The Transition to Eating By Mouth

When the infant is deemed medically appropriate to initiate oral feeding trials, the doctor may allow the infant to feed at the breast or bottle depending on the family’s preference and the infant’s ability. When the infant is learning to breastfeed, the SLP works in conjunction with the lactation consultant to ensure a successful feeding experience for both the infant and the mother.  The SLP will evaluate the infant before, during, and after the feeding attempt to determine the most appropriate feeding plan and recommendations.  Signs of feeding and swallowing difficulty that the SLP may be monitoring for during the feeding trials include (list is not exhaustive):

  • Audible gulping
  • “Stop” hands- the infant will hyperextend their extremities and hold up their hands in a “stop” fashion
  • Turning head away from the bottle
  • Pushing nipple out of the mouth
  • Biting on the nipple instead of sucking
  • Hiccups
  • Coughing
  • Color change to pale or blue
  • Holding breath with changes in heart rate, oxygen rate, and breathing rate2

Depending on the anatomic and physiologic assessment of the infant’s feeding and swallowing skills, the SLP may try different therapeutic interventions to improve the safety and efficiency of the eating experience for the infant. Some of these approaches include:

  • Changing the nipple to increase or decrease the flow rate of the formula or expressed breastmilk
  • Changing the feeding position of the infant
  • Assisting the infant by providing external pacing during the feeding
  • Imposing a rest break during the feeding5

SLPs perform an essential function as communication specialists during the transition to oral feeding in the NICU.  It is part of the SLP’s role to recognize and interpret the subtle communications that the infant provides during oral feeding and adjust the feeding as needed to help the infant achieve safe and adequate oral intake.  The SLP may recommend various instrumental swallowing assessments to assist in their diagnosis and management of the infant’s feeding and swallowing difficulties.  The SLP will also assist in making appropriate referrals at discharge to early intervention and other follow-up services to continue providing support for the infant after discharge.   

The end of Amy’s story

Amy was offered a bottle at 36 weeks postmenstrual age.  She was not ready to start oral feeding trials at 34 weeks postmenstrual age due to her respiratory status.  Amy completed her first bottle, requiring a slower flowing nipple, positioning on the side, and pacing by the SLP/feeder. The SLP helped the caregiver build confidence when feeding Amy and made recommendations for her to continue speech therapy after discharge. Amy will be screened and monitored for developmental delays, as these are often seen in infants born prematurely. 


1. Gennattasio, Annmarie, et al. “Oral Feeding Readiness Assessment in Premature Infants.” MCN: The American Journal of Maternal/Child Nursing, vol. 40, no. 2, Apr. 2015, pp. 96–104, doi:10.1097/NMC.0000000000000115.

2. Shaker, Catherine S. “Cue-Based Feeding in the NICU: Using the Infant’s Communication as a Guide.” Neonatal Network, vol. 32, no. 6, Jan. 2013, pp. 404–08, doi:10.1891/0730-0832.32.6.404.

3. Lubbe, Welma. “Clinicians Guide for Cue‐based Transition to Oral Feeding in Preterm Infants: An Easy‐to‐use Clinical Guide.” Journal of Evaluation in Clinical Practice, vol. 24, no. 1, Feb. 2018, pp. 80–88, doi:10.1111/jep.12721.

4. Thoyre, S. M., & Brown, R. L. (2004). Factors Contributing to Preterm Infant Engagement During Bottle-Feeding. Nursing Research, 53(5), 304–313.

5. Thoyre, Suzanne, et al. “Developing a Co-Regulated, Cue-Based Feeding Practice: The Critical Role of Assessment and Reflection.” Journal of Neonatal Nursing : JNN, vol. 19, no. 4, Aug. 2013, pp. 139–48, doi:10.1016/j.jnn.2013.01.002.

Rebecca Brown, M.S., CCC-SLP, CNT.  Rebecca is the Lead Inpatient Speech-Language Pathologist at CHRISTUS Good Shepherd Medical Center and primary SLP in the neonatal intensive care unit. Rebecca is responsible for the evaluation and treatment of medically complex neonates, adults, and geriatric patients in the ICU. She develops policies, procedures, and all of her team’s education. Rebecca is an adjunct instructor at two universities and is completing her Ph.D. in Health Sciences at Rocky Mountain University of Health Professions with a Neuro Rehab concentration. Rebecca serves on various committees at the local, state, and national level, including ASHA SIG 13 Professional Development Committee, TSHA Medical Executive Committee, IDDSI Task Force, and the Diversity & Inclusion Committee at Stephen F. Austin State University. Rebecca is a volunteer with Feeding Matters, Dysphagia Outreach Project, and the National Foundation of Swallowing Disorders. Rebecca is on the board of a local non-profit dedicated to the provision of education and resources for expectant parents.