INTRODUCTION — Safe and successful oral feeding in the neonate is dependent on the proper development of sucking and swallowing, and their coordination with breathing. Disruption of these coordinated functions can result in oral feeding difficulties leading to increased risk of apnea, bradycardia, failure to thrive, oxygen desaturation, or aspiration. As a result, identification of infants at risk for sucking and swallowing difficulties is important to prevent feeding disorders and potential serious complications.
This topic will review the development and physiology of sucking, swallowing, and aerodigestive protective mechanisms in the neonate. It will also discuss the evaluation and management approach for infants with feeding problems due to impaired sucking, swallowing, and their coordination. Swallowing dysfunction in older infants and children is discussed separately. (See "Evaluation of acute dysphagia in children" and "Aspiration due to swallowing dysfunction in children".)
DEFINITIONS — The terms used to discuss feeding difficulties in the newborn include the following:
●Sucking refers to the oromotor phase of the feeding cycle, in which a partial vacuum is produced by the lips and tongue. (See 'Sucking' below.)
It can be classified as follows:
•Nutritive sucking involves extraction of fluids (eg, human milk or formula) from the mother's breast or bottle and is coordinated with swallowing.
•Nonnutritive sucking occurs when the infant sucks on a pacifier, finger, or emptied breast and no milk is transferred. It is not always associated with swallowing .
●Swallowing involves the coordinated movement of producing a bolus of fluid (human milk or formula) and moving it from the oral cavity through the pharyngeal cavity, past the adducted vocal folds, across the relaxed cricopharyngeus (the main constituent of the upper esophageal sphincter [UES]), and into the distal esophagus and stomach [2,3]. (See 'Safe swallowing' below.)
●Dysphagia is defined as difficult or abnormal swallowing. It can be classified as follows:
•Oropharyngeal or transfer dysphagia characterized by difficulty initiating or coordinating a swallow.
•Esophageal dysphagia characterized by difficulty during the esophageal phase of swallowing [2,3].
●Aerodigestive protection is a coordinated movement of several anatomic organs to ensure safe breathing while swallowing. It involves the coordinated functions of nasopharynx, oropharynx, hypopharynx, esophagus, and stomach, thereby protecting the supraglottic, glottic, and subglottic tubular airways [2,3].
DEVELOPMENT AND PHYSIOLOGY OF ORAL FEEDING
Developmental overview — For successful oral feeding, the neonate needs to successfully coordinate sucking and swallowing that results in milk extraction from either the breast or bottle (nutritive sucking), bolus formation and its transport safely through the upper digestive tract (swallowing along with concurrent aerodigestive protection). Developmental organization of this process begins in utero, but mature sucking and swallowing may not be fully developed in very preterm (gestational age [GA] <32 weeks) [4-6]. As a result, VPT infants can have feeding difficulties with increased risk of apnea, bradycardia, failure to thrive, oxygen desaturation, or aspiration.
●In the first trimester between 18 and 24 weeks GA, primitive pharyngeal swallowing and anterior to posterior tongues movements are detected.
●Between 26 to 29 weeks GA, nonnutritive sucking may be present and can be promoted by the use of a pacifier.
●Between 32 weeks gestation and term, infants learn to coordinate sucking and swallowing with breathing, and develop adaptive aerodigestive protective mechanisms [7,8].
•At 34 weeks GA, sucking becomes more rhythmic and organized, and this is the earliest that infants can maintain full nutrition and hydration orally.
•At term, infants are able to normally coordinate sucking, swallowing, and breathing.
Sucking — Sucking refers to the oromotor phase of the feeding cycle, in which a partial vacuum is produced by the lips and tongue. It can be classified as either nonnutritive or nutritive sucking.
●Nutritive sucking — Nutritive sucking requires appropriate integration and synchronization of lips, cheeks, tongue, and palatal movements in order to express milk into the oral cavity . Mature nutritive sucking consists of a rhythmic alternation between suction and expression (waveform 1) [8-10]. Suction corresponds to the negative intraoral pressure exerted by the infant when milk is drawn into the mouth, which requires the sequential activation of the perioral muscles (temporal, masseter, orbicular, and suprahyoid muscles) [9-13]. Expression corresponds to the positive pressure resulting from mouthing, stripping, and/or compression of the nipple between the tongue and the hard palate to eject milk from the nipple and requires synchronization of the lingual musculature .
•In normal term infants, mature nutritive sucking is usually fully developed.
•For preterm infants by approximately 33 to 34 weeks postmenstrual age (PMA), infants begin to display nutritive sucking skills . Although the sucking pattern in preterm infants appears similar to that of term infants [1,16], initial sucking in very preterm infants is characterized by arrhythmic suction and/or expression. With maturation, the alternation of suction and expression gains in rhythmicity and amplitude, which leads to more efficient and rapid feeding. Oral feeding performance manifested by the volume transferred improves with maturation as sucking skills mature . Infants with immature sucking that consists only of expression capability may be able to bottle-feed before they can successfully breastfeed because suction is necessary for breastfeeding to draw milk into the mouth and/or prevent retraction of the teat. [9,17-20]. This is not needed for bottle feeding, as milk continuously fills the nipple chamber and the nipple is more rigid .
●Nonnutritive sucking — Nonnutritive sucking occurs when the infant sucks on a pacifier or finger, and no milk is transferred. The pattern is similar to nutritive sucking, but sucking and pause bursts are briefer and sucking frequency is faster (2 versus 1 sucks/second, respectively) (figure 1) . Although nonnutritive sucking matures earlier than nutritive sucking, it is not a good indicator of an infant's ability to feed orally because swallowing and laryngeal closure are minimal [4,21]. Nonnutritive sucking reduces stress, and promotes weight gain and gastrointestinal maturation and growth.
Safe swallowing — Safe swallowing involves the coordinated movement muscles of the upper digestive tract that results in development of a fluid bolus (human milk or formula) and its movement from the oral cavity through the contracted pharynx, across the relaxed components of the upper esophageal sphincter (UES), and into the distal esophagus and stomach. Safe swallowing involves the coordinated contraction of the pharynx, relaxation of the upper esophageal sphincter, and aerodigestive protective mechanisms that prevent reflux into the nasopharynx and airways (waveform 1).
●Swallowing consists of three phases that result in a coordinated process of moving a bolus from the oral cavity to the stomach. For infants, it is thought that an external stimulus such as a milk bolus is needed to stimulate the swallowing center of infants, which is not needed in older individuals . Indirect support for this theory is that during nonnutritive sucking, there is minimal observed swallowing and data that demonstrates different response rates of swallowing to air or sterile water provocative stimuli . (See "Oropharyngeal dysphagia: Etiology and pathogenesis", section on 'Physiology of swallowing' and "Aspiration due to swallowing dysfunction in children", section on 'Sequence of swallowing'.)
•Oral preparatory phase – During the oral phase, a bolus is formed in the oral cavity that is appropriate size to move through the pharynx and esophagus.
•Pharyngeal phase – In the pharyngeal phase, the bolus is transported through the pharynx and into the esophagus by pharyngeal peristalsis.
•Esophageal phase – In the esophageal phase, peristaltic contractions of the esophagus propel the bolus through the distal esophagus and into the stomach. Esophageal function begins in the fetus as the primitive esophagus transports swallowed amniotic fluid into the stomach. This is referred to as deglutitive pharyngo-esophageal peristaltic reflex, which results in coordinated sequential esophageal body peristalsis and relaxation of the lower esophageal sphincter (LES) [24,25]. Coordination of LES relaxation with respiration is observed at 33 weeks PMA with continued maturation of the deglutitive pharyngo-esophageal peristaltic reflex with advancing PMA to term equivalent [26-30].
However, preterm infants appear to have immature esophageal motility. Motility patterns are divided into peristaltic contractility with propagation in either ante- or retrograde direction, and nonperistaltic contractility that results in synchronous contractions or incomplete peristalsis [31,32]. Studies of preterm infants at 33 and 38 weeks PMA showed significantly fewer propagating peristaltic than nonperistaltic motor patterns . There is also evidence that some infants born prematurely may develop inappropriate patterns of esophageal motility, which delay their ability to successfully oral feed .
●Aerodigestive protection — Aerodigestive protection of the oropharyngeal and airway structures is provided by several reflexes, which are mediated by the interaction of afferent and efferent neuronal pathways of the pharynx and esophagus. These coordinated mechanisms collectively prevent the ascending spread of the bolus, favor descending propulsion of the bolus to ensure esophageal clearance, and protect the airways [27,29,30,34].
Sucking-swallowing-breathing coordination — Proper coordination of sucking, swallowing, and breathing allows for optimal oral feeding by minimizing the risk of aspiration and maintaining respiration with no or minimal effects on air exchange (waveform 1). Lack of coordination may result in aspiration, and episodes of oxygen desaturation, apnea, and/or bradycardia [7,35-37].
The normal respiratory rate of neonates is between 40 and 60 breaths/minute or 1 to 1.5 cycle/second. The duration of a swallow can vary between 0.35 and 0.7 seconds. Because air flow is interrupted during a swallow, an increase in the frequency of swallowing or breathing may result in decreased gas exchange as respiration is hampered . As a result, it may not be safe to orally feed infants with respiratory distress who present with tachypnea.
ETIOLOGY — The main causes of feeding problems due to sucking and swallowing disorders in the neonate include:
●Anatomic abnormalities, which may be associated with genetic or syndromic conditions
●Functional abnormalities of the pharynx or esophagus, which may be associated with neuromuscular disorders
Anatomic abnormalities — Anatomic abnormalities that affect any of the structures associated with sucking or swallowing can negatively impact oral feeding.
●Craniofacial anomalies (eg, Treacher and Robin Sequence syndromes, also referred to as Pierre Robin sequence or syndrome) (see "Syndromes with craniofacial abnormalities")
●Pharyngeal clefts and webs (eg, cleft lip and palate) (see "Congenital anomalies of the jaw, mouth, oral cavity, and pharynx")
●Esophageal atresia or trachea-esophageal fistula (see "Congenital anomalies of the intrathoracic airways and tracheoesophageal fistula", section on 'Tracheoesophageal fistula and esophageal atresia')
●Gastrointestinal anomalies – Omphalocele, gastroschisis, duodenal atresia or web, hiatus hernia, diaphragmatic hernia, intestinal malrotation, and hypertrophic pyloric stenosis
●Esophageal compression – External compression on the esophagus resulting in obstruction due to pressure from the trachea or left bronchus, left atrial enlargement, or post-cardiothoracic surgery complications.
Functional abnormalities — Difficulties in swallowing may be due to mechanical or functional obstruction, dysmotility, stasis and delayed peristalsis, gastroesophageal reflux disease (GERD) or neuromuscular disorders (see "Gastroesophageal reflux in infants" and "Gastroesophageal reflux in premature infants").
Neurologic disorders that cause impaired sucking and swallowing include the following:
●Central nervous system disorders – Congenital brainstem lesions, such as Dandy-Walker syndrome (malformation of the posterior fossa), cerebral palsy, or complications from neonatal encephalopathy.
●Peripheral neuromuscular disorders – Spinal muscular atrophy 1, congenital myopathies, neuromuscular junction disorders such as neonatal myasthenia gravis and infantile botulism (table 1), and disorders that present with neonatal hypotonia (Prader-Willi and Down syndrome). (See "Spinal muscular atrophy" and "Overview of peripheral nerve and muscle disorders causing hypotonia in the newborn".)
Impaired function may be seen in infants with sepsis and metabolic diseases (disorders of amino acid metabolism, urea cycle defects, galactosemia, and congenital adrenal hyperplasia) . (See "Clinical manifestations and diagnosis of eosinophilic esophagitis (EoE)", section on 'Clinical manifestations in children'.)
Prematurity — As discussed above, oral feedings are challenging for very preterm infants (gestational age [GA] <32 weeks) as they have not developed mature sucking and swallowing mechanisms, do not have adequate aerodigestive reflexes to prevent reflux and protect their airways, and often have immature esophageal motility. Feeding difficulties due to poor coordination of sucking and swallowing may persist in preterm infants at term equivalent age . (See 'Development and physiology of oral feeding' above.)
Preterm infants are at risk for aspiration of milk before, during, or after deglutition as follows :
●Predeglutitive aspiration – Improper formation of a bolus during the oral motor phase may result in liquid pushed into the oropharyngeal region while the glottis remains open.
●Intradeglutitive aspiration – Improper closure of the larynx during swallowing may result in liquid penetration into the airway.
●Postdeglutitive aspiration – Residual liquid in the valleculae and pyriform sinuses may lead to aspiration when the larynx reopens after the swallow.
CLINICAL MANIFESTATIONS — The clinical presentation of neonatal sucking and swallowing disorders ranges from serious events, such as aspiration events, to more subtle and nonspecific findings including poor weight gain.
The following are signs and symptoms of swallowing and feeding disorders in the neonate:
•Poor suck and inability to latch properly to mother's breast
•Pooling of milk in the mouth and difficulty in initiating swallow
•Fussiness, crying, or back arching as signs of discomfort
•Episode(s) of apnea, choking, cyanosis or other acute event during feeding (see "Acute events in infancy including brief resolved unexplained event (BRUE)")
●Respiratory symptoms or findings
•Signs of respiratory distress during feeding such as skin color turning blue or dusky, or increased respiratory rate
●Failure to thrive
Goal — The goal of the diagnostic evaluation is to determine the underlying etiology of feeding difficulties due to sucking or swallowing dysfunction (dysphagia). The initial assessment is based on history, physical examination, and observation of the infant while feeding. The need and choice for further diagnostic evaluation are guided by the results of the initial assessment or clinical setting.
History and physical examination — In some cases, the underlying cause of dysphagia (eg, cleft palate) is readily apparent on physical examination. In other neonates, the etiology is also self-evident based on the history (eg, prematurity with a gestational age less than 32 weeks). However, in some patients, determining the underlying etiology may be more challenging. In this setting without a clear etiology, the history and physical examination may be useful in identifying the underlying cause.
The history should review the following:
●Maternal history such as diabetes, hypertension, multiple drug use. In such conditions, delays with transition and maturational dysfunctions can be expected and result in poor feeding due to autonomic dysfunction. This may be observed in infants with neonatal abstinence syndrome (NAS), altered neuromuscular tone, and those with increased somnolence. (See "Prenatal substance exposure and neonatal abstinence syndrome (NAS): Clinical features and diagnosis", section on 'Clinical manifestations of NAS'.)
●Antenatal history such as polyhydramnios. Polyhydramnios (excessive volume of amniotic fluid) may be due to impaired fetal swallowing of amniotic fluid, which can be observed in fetuses with obstructive gastrointestinal tract anomalies or neuromuscular disorders. (See "Polyhydramnios: Etiology, diagnosis, and management", section on 'Fetal anomalies' and "Polyhydramnios: Etiology, diagnosis, and management", section on 'Neuromuscular disorders'.)
●Gestational age at birth, and postmenstrual age (PMA) at time of presentation.
●Birth history (eg, birth asphyxia, Apgar score, traumatic delivery).
●Neonatal hospital course (history of airway intubation and mechanical ventilation, sepsis, intraventricular hemorrhage, and cardiothoracic surgeries including patent ductus arteriosus ligations, and those for congenital heart disease, congenital hypothyroidism, or inborn errors of metabolism).
●Symptoms during feeding such as color change (blue), coughing or gagging, choking, crying (sign of discomfort), or changes in respiratory pattern, or apparent life-threatening event may be suggestive of aspiration.
●Other symptoms not related to feeding: continuous drooling (poor swallow), abnormal upper airway noise (anatomic defect), poor head control (hypotonia).
●Growth, especially evidence of poor weight gain.
The physical examination includes:
●Measurement of height and weight, and assessment of weight gain to detect poor weight gain
●Assessment of face, jaw, lips, tongue, hard and soft palate, oral pharynx, and oral mucosa to detect structural abnormalities
●Neurologic assessment of tone including sucking, rooting and Moro's, head-neck control, and tone in extremities and trunk (see "Neurologic examination of the newborn")
Feeding assessment — In the neonate, including in preterm infants, assessment includes evaluation of pre-feeding skills, readiness for oral feeding, and the ability to breast and bottle-feed . This is best judged by a clinician with expertise in the anatomy and physiology of sucking, swallowing, and respiration during either breast or bottle-feeding.
Neonatal intensive care setting — The prevalence of feeding difficulties is high for infants who are cared for in the neonatal intensive care unit (NICU) . The initial assessment of infants cared for in the NICU determines whether or not individual infants have attained the milestones necessary for successful and safe oral feeding [40,42].
●Pre-feeding readiness based on the infant's PMA and the medical stability of the patient. Infants less than 32 weeks PMA are not developmentally mature enough to have developed nutritive sucking, a prerequisite for successful oral feeding (see 'Sucking' above). In addition, infants who are medically unstable (eg, those requiring mechanical ventilation) are not candidates for oral feeding as they cannot protect their airway.
●Oral readiness criteria include medical stability (eg, no evidence of respiratory distress or cardiovascular instability), >33 to 34 weeks PMA, adequate level of arousal, and the presence of a nonnutritive sucking pattern (positive pressure of the mandible and tongue on the pacifier) and suction (negative pressure in the oral cavity generated by movement of the mandible in an inferior-anterior trajectory).
●Neonatal feeding assessment is performed once the infant has attained both pre-feeding and oral readiness milestones and oral feeds have been initiated. Neonatal feeding assessment is conducted on infants for both breast and bottle-feeding. Assessment should be performed by an experienced clinician (eg, occupational and speech therapists). Evaluation includes assessing:
•Nutritive sucking – Nutritive sucking assessment is best performed when the infant displays feeding readiness cues and is physiologically stable. Nutritive sucking assessment is based on identifying the magnitude and temporal characteristics of sucking physiology, as well as the resulting volume and rate of milk ingestion. It begins with evaluating the infant's state of alertness, rooting reflexes, and sucking skills and rhythm. This is followed with an assessment during breastfeeding or bottle-feeding of the latch, the presence of rhythmic sucking bursts with pauses, and regulation of respiration to prevent aspiration.
•Pharyngeal swallowing – Pharyngeal assessment includes noting any delayed or absent pharyngeal swallow, reduced movement of the hyolaryngeal complex (ie, upward and anterior movement of hyoid), and excessive number of swallows per bolus. Excessive number of pharyngeal swallows suggests larger bolus volumes, which may fill the pharynx before clearing and can pose a risk for aspiration. Affected infants may display coughing, chocking or eye tearing during feeds, and reduced cardiopulmonary stability (eg, bradycardia). If any of these findings are present, further evaluation is warranted and includes videofluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallow (FEES), which provide direct visualization of pharyngeal swallow and bolus flow. (See 'Tests to detect anatomic defects and assess swallowing' below.)
•Sucking, swallowing, and respiratory coordination – Clinical assessment relies largely on the subjective assessment of rhythmic respirations and cardiopulmonary stability during suck-bursts and suck-burst breaks during feeding. Evidence of poor coordination includes paradoxical respiratory movements during suck-bursts and stridor or prolonged apnea during swallowing. In some situations, lack of coordination can result in choking and coughing, and in some infants with bradycardia may result in pallor or cyanosis.
Nonintensive care setting — For infants who are not cared for in the NICU, the assessment is usually based on direct observation of feeding that includes the evaluation of the sucking/swallowing/breathing pattern, efficiency, and endurance during feeding. This can be done by occupational therapists on an outpatient and inpatient basis.
Further diagnostic evaluation — Further diagnostic evaluation is guided by the clinical setting as individual tests are helpful in determining specific causes of dysphagia.
Tests to detect anatomic defects and assess swallowing — Videofluoroscopic swallow study (VFSS) and gastrointestinal fluoroscopy are radiologic tests used to detect anatomic defects of the aerodigestive tract. In addition, VFS studies assess the swallowing dynamics. In some cases (eg, infants with stridor), direct visualization may be more useful.
●Videofluoroscopic swallow study (VFSS) — The VFSS, also known as the modified barium swallow study (MBSS), is the most commonly used diagnostic test in the evaluation of oropharyngeal dysphagia and may be used as a guide for management decisions and feeding strategies. It as a fluoroscopic evaluation of the swallowing process (including its timing) from initial formation of the bolus and its transfer from the oral cavity through the pharynx and esophageus into the stomach. VFSS detects impaired bolus flow due to insufficient contraction of the oropharyngeal structures and/or anatomic abnormalities, and associated reflux.
•Indications ‒ VFSS is indicated if there is a need to observe the patient's swallowing biomechanics based an abnormal feeding assessment. These include persistent feeding refusal, suspected anatomic or functional defect of the oral, pharyngeal, or upper esophagus or concern for aspiration.
VFSS can also be used to evaluate the effectiveness of management demonstrating improved oropharyngeal swallowing using compensatory strategies (ie, alteration of nipple type, bolus viscosity, infant position, and feeding method [by bottle or breast feeding]).
•Limitations and concerns
-The use of VFSS alone in the decision-making process of when to begin enteral feeds may result in delayed initiation and presentation of nutritive oral stimuli . The lack of such stimulation can deprive the development of infant swallowing and airway protection skills. Therefore, the VFSS results should not be the sole determinant of readiness/competence to feed orally.
-VFSS is associated with significant radiation exposure, which is equivalent to exposure from multiple chest radiographs.
●Upper gastrointestinal fluoroscopy — Any infant experiencing oropharyngeal dysphagia, apparent life-threatening events, and excessive emesis or reflux may need structural evaluation using upper gastrointestinal fluoroscopy. Upper gastrointestinal fluoroscopy is best utilized to identify gastrointestinal anatomic abnormalities and structural defects such as hiatal hernias, pyloric stenosis, malrotation, esophageal and antral webs, or even more distal lesions such as intestinal atresia and stenosis . However, this study lacks adequate sensitivity and specificity to screen for either dysphagia or gastroesophageal reflux disease (GERD), and is associated with significant radiation exposure. Therefore, such studies should be considered when structural abnormalities are suspected to cause severe swallowing and airway symptoms .
●Direct visualization — Fiberoptic endoscopic evaluation of swallowing (FEES) is performed by a specially-trained pediatric otolaryngologist and may be particularly useful for infants with stridor or regression of oral feeding skills. It provides direct visualization of the upper airway anatomy structure and function and can detect anatomical abnormalities of the airway such as vocal cord cyst and granuloma, vocal cord paralysis, laryngomalacia, and subglottic stenosis, which may affect swallowing and result in poor feeding. (See "Aspiration due to swallowing dysfunction in children", section on 'Fiberoptic endoscopic evaluation of swallowing'.)
Tests to detect gastroesophageal reflux — Infants with gastroesophageal reflux present with frequent bouts of regurgitation, which may have pathologic consequences, such as esophagitis, nutritional compromise with weight loss, or respiratory complications. Further workup may be warranted in these infants and may include esophageal pH-multichannel intraluminal impedance (pH-MII) testing. The clinical presentation, evaluation, and management of GER are discussed separately. (See "Gastroesophageal reflux in premature infants".)
Tests to assess esophageal motility — Basal and adaptive esophageal manometry identifies peristaltic and sphincteric dysfunction of the esophagus. Conventional esophageal basal and adaptive manometry studies in neonates provide information on esophageal pressures and peristalsis, velocity of propagation, and sphincter responses to swallow and reflux events [23,26,28,30,46,47]. The addition of high resolution manometry adds more sensors that enhance spatial and temporal resolution across the esophagus compared with conventional manometry . The combination of esophageal manometry and pH-MII provides simultaneous information in bolus transit and motility. However, these procedures require highly skilled, experienced personnel who are familiar with testing, including patient safety issues, symptom correlation, interpretation, and analysis. As a result, these tests are only available in specialty motility programs, including at our center. They do provide functional assessment of motility, which is helpful for guiding further management decisions.
Goal — The focus of the treatment plan is to optimize feeding by promoting oral motor skills for at-risk infants (eg, maturing preterm infants, and those with neuromuscular disorders and congenital anomalies) and, if necessary, provide supplemental nutrition via alternative feeding strategies to ensure adequate growth (eg, gastrostomy tube in infants with intractable neuromuscular disorders) and to identify underlying causes that are correctable (eg, cleft lip or palate).
●Multidisciplinary team ‒ Neonates with feeding disorders benefit from a multidisciplinary approach, which may include the following team members .
•Nutritionist to perform a dietary evaluation and make adjustments in feeding.
•Occupational and speech therapists to assess oromotor and swallowing function and plan feeding strategy.
•Psychologist to evaluate maternal and infant behavior and mother-infant interaction.
•Pediatrician to coordinate and supervise the team and follow up as needed.
•Specialists who are consulted for specific issues including:
-Pediatric gastroenterologist to identify gastrointestinal disorders, if any, and to develop specific therapies.
-Lactation consultant for breastfeeding issues.
-Pulmonologist to address respiratory disease related to gastroesophageal reflux disease (GERD) or dysphagia.
-Otolaryngologist to address airway and pharynx pathologies.
●Individualized management ‒ Management needs to be individualized based on the infant's underlying diagnosis, maturity, and both the infant's and parents'/caregivers' skill sets . Initial and ongoing education and support of the family/caregiver is essential for successful management.
●Duration of treatment ‒ In general, correction of a feeding disorder requires weeks to months. Regular follow-up is needed to assess progress and compliance with treatment and to revise the treatment plan as needed.
Techniques and tools
Breastfeeding — Problems with sucking, swallowing, and coordination with breathing may interfere with successful breastfeeding. Specific interventions depend upon the underlying etiology and are discussed in detail separately.
These include the following:
●Preterm infant. (See "Breastfeeding the preterm infant".)
●Arousal techniques for infants to maintain a state of arousal adequate for oral feeding. (see "Initiation of breastfeeding", section on 'Principles of breastfeeding')
●Positioning techniques, such as the football hold, to provide more cheek and jaw support than does the traditional cradle hold. This may help infants obtain a better latch needed for successful breastfeeding. (See "Initiation of breastfeeding", section on 'Positioning and effective (asymmetric) latch'.)
●A thin silicone nipple shield may help infants who have difficulty remaining on the breast .
Adaptive feeding equipment — In some cases, the use of adaptive feeding equipment may be useful to control bolus size or rate of flow for infants with sucking or swallowing disorders who are bottle-fed. This includes changes in nipple size and consistency, size of the nipple hole, and bottle compressibility. Speech and occupational therapists may use the results of a feeding assessment or videofluoroscopy swallowing study (VFSS) to guide decisions on the use of specific adaptive feeding equipment.
Gastrostomy feeding — Gastrostomy tube feeding is recommended as a long-term feeding strategy for infants with persistent dysphagia or those with an intractable underlying condition (eg, congenital neuromuscular disorder). However, if there is any expectation that the infant could learn to feed orally, early and consistent oromotor training is required to develop oral feeding skills in order to successfully transition from tube feeds to oral feeds and avoid feeding aversion.
There are currently no guidelines for the timing of insertion of gastrostomy tubes in infants who are not able to feed orally. In our practice, gastrostomy tube feedings are considered for infants who are not able to take adequate oral feeds safely to support optimal growth, including infants who have been dependent on nasogastric tube feeding to provide essential nutrients. Gastrostomy tube feeding provides a safe and comfortable alternative to nasogastric tube feeding. The prolonged use of nasogastric tubes can lead to complications, including discomfort, nasopharyngeal irritation, gastroesophageal reflux (GER), increased upper airway resistance, and feeding aversion behaviors such as agitation, arching, tongue thrusting, gagging, and vomiting [17,22,52,53].
Specific neonatal groups
Preterm infants — Successful implementation of oral feeding in the preterm infant is dependent on acquiring the oral skills indicating readiness to feed (nonnutritive sucking and rooting) and developing aerodigestive protective reflexes during swallowing as the infant matures. Feeding protocols that provide clear guidance for the initiation (eg, readiness) and advancement of oral feeding have shortened the time to successful full oral feedings for both breastfeeding and formula-fed preterm infants . (See "Approach to enteral nutrition in the premature infant".)
Cleft lip or palate — Infants with a cleft lip (prior to surgical correction) have difficulty in producing the negative pressure required to extract milk into the oral cavity.
●Bottle-fed infants ‒ Infants who are bottle-fed may feed more efficiently using a soft teat (easier to compress) with a large hole to improve flow In addition, a flexible (squeezable) bottle may be used to enhance milk flow as needed .
●Breastfed infants ‒ Infants need to be evaluated individually on their ability to generate sufficient suction for successful breastfeeding. Individuals who wish to breastfeed should be referred to a lactation specialist for assistance regarding infant positioning and management/expression of milk. Information for breastfeeding for infants with cleft lip and palate is provided by a guideline for breastfeeding infants with cleft lip and palates from the Academy of Breastfeeding Medicine.
Severe intractable swallowing disorders — For infants with persistent severe dysphagia or those with an intractable underlying condition (eg, congenital neuromuscular disorder), gastrostomy tube feeding is recommended as a long-term feeding strategy to provide optimal therapy for patients who are unable to adequately and safely orally feed. (See "Management of gastroesophageal reflux disease in children and adolescents", section on 'Gastrostomy placement' and "Aspiration due to swallowing dysfunction in children", section on 'Gastrostomy feeding'.)
LONG-TERM OUTCOME — The consequences of impaired oral feeding functions in early life remains uncertain. In a retrospective review, 31 of 117 infants were discharged home on gastrostomy feeds and were more likely to have lower composite scores on cognition, communication, and motor function tests than those discharged home on oral feedings . However, these patients also were more likely to be born at an earlier gestational age and have comorbid conditions including bronchopulmonary dysplasia and intraventricular hemorrhage.
SUMMARY AND RECOMMENDATIONS
●Clinical significance ‒ Safe and successful oral feeding in the neonate is dependent on the proper development of sucking and swallowing, and their coordination with breathing. Disruption of these coordinated functions can result in feeding difficulties leading to increased risk of apnea, bradycardia, failure to thrive, oxygen desaturation, or aspiration. (See 'Development and physiology of oral feeding' above.)
●Sucking ‒ Sucking refers to the oromotor phase of the feeding cycle, in which a partial vacuum is produced by the lips and tongue. It is classified as either nonnutritive or nutritive sucking. Nutritive sucking is needed for successful oral feeding, and does not begin to develop until 32 weeks postmenstrual age (PMA). It consists of a rhythmic alternation between suction and expression that requires appropriate integration and synchronization of lips, cheeks, tongue, and palatal movements. (See 'Sucking' above.)
●Swallowing ‒ Swallowing involves the coordinated movement of producing a bolus of fluid (human milk or formula) and moving it from the oral cavity through the contracted pharynx, across the relaxed upper esophageal sphincter (UES), and into the distal esophagus and stomach. Safe swallowing involves the coordinated contraction of the pharynx, relaxation of the upper esophageal sphincter, and aerodigestive protective mechanisms that prevent reflux into the nasopharynx and airways (waveform 1). (See 'Safe swallowing' above.)
●Etiology ‒ The main causes of sucking and swallowing disorders that result in neonatal feeding problems include anatomical defects (eg, cleft lip or palate), functional abnormalities of the pharynx or esophagus (eg, dysmotility or neurologic disorders), and prematurity. (See 'Etiology' above.)
●Clinical manifestations ‒ The clinical presentation of neonatal sucking and swallowing disorders ranges from serious events, such as aspiration events or an apparent life-threatening event, to more subtle and nonspecific findings including feeding difficulties and poor weight gain. (See 'Clinical manifestations' above.)
●Diagnostic evaluation ‒ The goal of the diagnostic evaluation is to determine the underlying etiology. It includes an initial assessment based on history, physical examination, and observation of the infant while feeding.
•Neonatal feeding assessment includes evaluation of pre-feeding skills, readiness for oral feeding, and the ability to breast and bottle-feed. It is best performed by an experienced clinician (eg, occupational or speech therapist). The assessment typically entails evaluation of nutritive sucking, pharyngeal swallowing, and coordination of sucking, swallowing, and breathing. (See 'Feeding assessment' above.)
•The need and choice for further diagnostic evaluation are guided by the results of the initial assessment or clinical setting. Further diagnostic tests include videofluoroscopy swallow study (VFSS), reflux monitoring tests, and esophageal motility tests (manometry). (See 'Diagnostic evaluation' above.)
●Management ‒ The goal of the treatment plan is to optimize feeding by promoting oral motor skills (eg, preterm infants), and if necessary, provide supplemental nutrition via alternative feeding strategies to ensure adequate growth (eg, gastrostomy tube in infants with intractable neuromuscular disorders) and to identify underlying causes that are correctable (eg, cleft lip or palate). (See 'Management approach' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Chantal Lau, PhD, who contributed to an earlier version of this topic review.
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